Pre-existing, incidental and hemorrhagic AVMs in pregnancy and postpartum: Gestational age, morbidity and mortality, management and risk to the fetus

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.

Cerebral arteriovenous malformations during pregnancy: a management dilemma

The rupture of a brain cranial arteriovenous malformation (bAVM) has been associated with pregnancy; however, due to scarcity of data about this rare condition, management still remains a dilemma both for obstetricians and neurophysicians. The management plan is decided after weighing the benefits of bAVM treatment against the risk of bleeding in pregnancy. There is consensus on deciding the treatment of ruptured brain AVM during pregnancy based on neurological and not obstetrical indications. The management is decided using a multidisciplinary approach.We report the case of a primigravida who presented at 15 weeks of gestation with intracranial haemorrhage secondary to ruptured bAVM, which was managed by glue embolisation. However, she presented again after 9 days in a moribund condition with fever, vomiting and malaise. The family was very concerned about the patient. The multidisciplinary team after evaluation of patient decided for hysterotomy based on the deteriorating maternal condition.

Cerebral arteriovenous malformation rupture in pregnancy

A 30-year-old nulliparous woman at 38 5/7 weeks of gestation developed a sudden, severe headache at work and subsequent loss of consciousness. She underwent evaluation in the emergency department. CT and CT angiogram head revealed a large intraparenchymal haematoma with intraventricular extension secondary to ruptured cerebral arteriovenous malformation (cAVM). She was intubated and transferred to a tertiary care centre. The patient underwent caesarean section followed by partial embolisation of the cAVM with planned second embolisation and resection 1 week later. Due to drowsiness and headache, the planned repeat embolisation and cAVM resection were performed 3 days earlier. The patient had a full recovery. Emergency medicine physicians and obstetrician-gynaecologists should be familiar with differential diagnosis of sudden headache in pregnancy and signs of a ruptured cAVM to facilitate early diagnosis, multidisciplinary team approach and timely treatment. Early diagnosis and management of ruptured cAVM are important due to associated morbidity and mortality.