Brain Arteriovenous Malformations and Pregnancy: A Systematic Review of the Literature.

Background: The bleeding risk and outcome of pregnant women harboring intracranial arteriovenous malformations are still unclear, and no consensus has been achieved on management timing and strategy.

Methods: We searched PubMed, MEDLINE, and EMBASE from 1990 to 2022 for studies evaluating the bleeding risk and the outcome of women with intracranial arteriovenous malformations. Our primary end point was the hemorrhage rate. The secondary end points were pregnancy outcome and treatment safety for the mother and the fetus.

Results: Nine studies reporting on 2426 women were included. The overall hemorrhage rate in untreated women was 2.6%. The rate of first bleeding during pregnancy and postpartum was greater than the respective fertile period in unpregnant women (11% vs. 6.7%). The risk of first bleeding was greater in the II and III trimesters (4.5% and 2.9%), while was lower during delivery and puerperium (0.1% and 0.2%). The majority of the women did not report any complications after pregnancy and early postpartum death occurred in 4.1% of cases. The overall miscarriage rate was 12.4%.

Conclusions: Women harboring intracranial arteriovenous malformations appear to have a greater risk of hemorrhage during pregnancy. There is an increased bleeding risk in the later stages of gestation, whereas delivery and puerperium are less risky phases. Outcomes are relatively good for the mother, with low rates of mortality and unfavorable sequelae, but there is a risk of miscarriage for the fetus. Intervention should be undertaken prophylactically before pregnancy or during early gestation if possible. For pregnant women who deferred treatment, multidisciplinary management is advised.