Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts 02115, USA.
Neurosurgery. 2012 Aug;71(2):349-55; discussion 355-6. doi: 10.1227/NEU.0b013e318256c34b.
Previous hemorrhage, deep venous drainage, and deep location are established risk factors for arteriovenous malformation (AVM) hemorrhage. Although pregnancy is an assumed risk factor, there is a relative paucity of data to support this neurosurgical tenet.
To elucidate the hemorrhage rate of AVMs during pregnancy.
We reviewed the records of 54 women with an angiographic diagnosis of an AVM at our institution. Annual hemorrhage rates were calculated as the ratio of the number of bleeds to total number of patient-years of follow-up. Patient-years of follow-up were tallied assuming lesion presence from birth until AVM obliteration. The Cox proportional hazards model for hemorrhage with pregnancy as the time-dependent variable was used to calculate the hazard ratio.
Five hemorrhages in 4 patients occurred over 62 pregnancies, yielding a hemorrhage rate of 8.1% per pregnancy or 10.8% per year. Over the remaining 2461.3 patient-years of follow-up, only 28 hemorrhages occurred, yielding an annual hemorrhage rate of 1.1%. The hazard ratio for hemorrhage during pregnancy was 7.91 (P = 2.23 × 10(-4)), increasing to 18.12 (P = 7.31 × 10(-5)) when limiting the analysis to patient follow-up up to age 40.
Because of the increased risk of hemorrhage from AVMs during pregnancy, we recommend intervention in women who desire to bear children, particularly if the AVM has bled. If the AVM is discovered during pregnancy, we recommend early intervention if it has ruptured; if it is unruptured, we recommend comprehensive counseling, weighing risks of intervention against continuation of pregnancy without intervention.
先前的出血、深静脉引流和深部位是动静脉畸形（AVM）出血的既定危险因素。尽管妊娠被认为是一个危险因素，但支持这一神经外科原则的相关数据相对较少。
阐明 AVM 在妊娠期间的出血率。
我们回顾了在我们机构接受血管造影诊断为 AVM 的 54 名女性的记录。每年的出血率计算为出血次数与总患者随访年数的比值。假设从出生到 AVM 闭塞时存在病变，计算患者随访年数。使用以妊娠为时间相关变量的 Cox 比例风险模型计算出血的风险比。
4 名患者的 5 次出血发生在 62 次妊娠中，出血率为每妊娠 8.1%或每年 10.8%。在其余的 2461.3 个患者随访年中，仅发生了 28 次出血，年出血率为 1.1%。妊娠期间出血的风险比为 7.91（P = 2.23×10(-4)），当将分析限制在 40 岁之前的患者随访时，风险比增加到 18.12（P = 7.31×10(-5)）。
由于 AVM 在妊娠期间出血的风险增加，我们建议希望生育的女性进行干预，特别是如果 AVM 已经出血。如果在妊娠期间发现 AVM，我们建议如果已经破裂，则早期干预；如果未破裂，则建议进行全面咨询，权衡干预的风险与不干预继续妊娠的风险。
