Maternal and Fetal Outcomes in Women with Brain Arteriovenous Malformation Rupture during Pregnancy

Intracranial Arteriovenous Malformations During Pregnancy and Puerperium-A Retrospective Nationwide Population-Based Cohort Study

BACKGROUND AND OBJECTIVES

The knowledge about the management of patients with brain arteriovenous malformations (AVM) during pregnancy is limited, owing partly to insufficient evidence about the outcomes of newborns. This study aims to explore symptomatic AVMs and their outcomes during pregnancy, delivery, and the postpartum period.

METHODS

We conducted a retrospective analysis by combining patients with symptomatic AVM from a nationwide population-based cohort of all women with a pregnancy resulting in delivery during 1987 to 2016 (n = 1 773 728 deliveries) and our AVM database (n = 805, 1942-2014). Cerebrovascular events during pregnancy were identified through International Classification of Diseases-9, International Classification of Diseases-10, or surgical procedure codes from the Hospital Discharge and Medical Birth Registers. Our analysis focused on treatment characteristics and outcomes of patients with AVM hemorrhage or symptomatic AVM during pregnancy, delivery, or puerperium.

RESULTS

A total of 28 women with symptomatic AVMs during pregnancy, delivery, or postpartum period were followed for an average of 12.8 years (SD = 15.5) after admission. Among them, 21 (75%) experienced AVM hemorrhages during pregnancy, puerperium, or delivery. The mean age of patients was 28.9 years (SD = 5.5). Hemorrhages occurred predominantly during the second (n = 9, 43% of all ruptures) or the third trimester (n = 5, 24%). Two AVM ruptures occurred during labor. Treatment for AVM took place during pregnancy (n = 7, 25%) or puerperium (n = 3, 14%) in 10 patients (35.7%). Only 5 mothers (17.8%) had not been previously pregnant. There was no significant difference in mean Apgar scores between those with AVM hemorrhage (8.3) and those without (8.4).

CONCLUSION

Most mothers in the study had prior pregnancies, suggesting a potentially weaker association between AVM rupture and pregnancy compared to previous reports. Notably, 2 AVM ruptures occurred during spontaneous vaginal deliveries. Outcomes were generally favorable in both mothers and infants. More research is needed to refine our understanding of the optimal timing for invasive treatment during pregnancy.

Embolization of Ruptured Infratentorial Pial AVM in Pregnancy

A primigravida 22-year-old woman, at a gestation of 23 weeks, experienced bleeding from a pial arteriovenous malformation (AVM) located in the right cerebellum. After interdisciplinary consensus and with the informed consent of the patient and her family, AVM embolization was performed. Complete occlusion of the AVM was achieved by embolization with PHIL (precipitating hydrophobic injectable liquid). The calculated dose in the uterus was less than 1 µSv, which represents a negligible risk of harmful effects on the fetus. She delivered a baby at 37 weeks of gestation by cesarean section without complications. No congenital disorders were diagnosed by standard screening methods until the age of the newborn was two years. The angiography protocol must be optimized to minimize the radiation dose. Adequate shielding protection of the uterus is important. Premature termination of pregnancy is not necessary. Multidisciplinary care of neurologists, neurosurgeons, interventional radiologists, anesthesiologists, neonatologists, and obstetricians is necessary.

Arteriovenous Malformation Hemorrhage in Pregnancy: A Systematic Review and Meta-Analysis

Hemorrhage of arteriovenous malformation (AVM) is a rare condition during pregnancy. This study was proposed to pool the proportion of AVM hemorrhage per pregnancy. A systematic review and meta-analysis with three databases were performed to review the studies published until April 2022. The Newcastle Ottawa Scale was used for risk assessment of data quality. The meta-analysis was conducted by a generic inverse variance of double arcsine transformation with a random model using Stata software. Twelve studies were included in this review. The pooled proportion of AVM hemorrhage per pregnancy was 0.16 (95% CI: 0.08, 0.26). The subgroup analyses were carried out based on world regions and study designs, and the study duration with the highest proportion of each subgroup was Europe [0.35 (95% CI: 0.02, 0.79)], with retrospective review [0.18 (95% CI: 007, 0.32)] and 10 to 20 years of study duration [0.37 (95% CI: 0.06, 0.77)]. The AVM hemorrhage per pregnancy in this review was considered low. However, the conclusion must be carefully interpreted since this review had a small study limitation.

Analysis of Perioperative Nursing Intervention Effect of Cerebrovascular Intervention Patients Based on Intelligent Internet of Things

The postoperative results of cerebrovascular surgery patients have been successfully used in medical practice using the Internet. The results obtained through data analysis were used in the study. So far, 120 patients who underwent cerebrovascular surgery from February 2018 to December 2018 have been enrolled. The selected class was divided into two groups: 60 psychiatric patients, a control group and an observation group. The former is medical treatment and the latter is postoperative treatment. Results: The results showed that the blood pressure of control group was lower than that of control group, and the incidence of adverse events was lower than that of control group ( $P<0.05$ ). Meanwhile, the average hospitalization rate of cerebrovascular disease patients in control group was lower than that in control group ( $P<0.05$ ). Conclusion: For patients with cerebrovascular disease, postoperative nursing can reduce the incidence of postoperative complications, reduce the risk of surgery, and improve the effect of surgery. Acute ischemic stroke refers to a kind of clinical syndrome caused by abnormal blood supply in the brain, resulting in ischemia, hypoxic brain tissue necrosis, and focal or comprehensive neurological deficiency. Among them, progressive cerebral infarction accounted for about 20~35%, and most occurred in the early stage of the disease (48~72)h.

Cerebrovascular disease in pregnancy and postpartum

PURPOSE OF REVIEW

Cerebrovascular disorders during pregnancy and puerperium are uncommon but potentially serious entities. This review aims to provide guidance on the diagnosis and management of these diseases, according to the most recent findings.

RECENT FINDINGS

Proteinuria is no longer a mandatory criterion for the diagnosis of preeclampsia. Favourable long-term foetal and maternal outcomes are achieved in most patients with ruptured cerebral arterial malformations during pregnancy receiving interventional treatment prior to delivery. Despite the recent recommendations, physicians still hesitate to administer thrombolysis in pregnant women. In women with a history of cerebral venous thrombosis, prophylaxis with low molecular weight heparin during pregnancy and puerperium is associated with lower rates of recurrent thrombotic events and miscarriage.

SUMMARY

Hypertensive disorders of pregnancy are a continuum of failure of autoregulation mechanisms that may lead to eclampsia, posterior reversible encephalopathy syndrome, reversible cerebral vasoconstriction syndrome and stroke. MRI is the preferred imaging modality of choice. In the absence of specific contraindications, treatment of cerebrovascular complications should not be withheld from pregnant women, including reperfusion therapies in acute ischemic stroke and treatment of ruptured cerebral aneurysms. Previous history of stroke alone does not contraindicate future pregnancy, but counselling and implementation of prevention strategies are needed.