Neurosurgical Management of Ruptured Arteriovenous Malformations During Pregnancy and Puerperium: An Institutional Experience, Systematic Review and Meta-Analysis

Introduction: Management of pregnant patients with ruptured arteriovenous malformations (AVMs) is a challenge to ensure the health of both the mother and fetus. This study presents our institutional experience and a meta-analysis of ruptured AVMs in pregnant patients.

Methods: Seven pregnant patients presented with ruptured AVMs between June 2005 and June 2023 at our institution. These were combined with the results of a systematic review and meta-analysis performed by searching MEDLINE, Cochrane, and Web of Science for studies on AVMs during pregnancy.

Results: In a review of 146 pregnant patients with ruptured AVMs (including 7 patients treated at our institution), rupture occurred in 7.6% of patients during the first trimester, 58.7% of patients during the second trimester and 33.7% during the third trimester. Emergency resection or decompression prior to delivery was performed in 38.7% of patients. One patient (0.97%) underwent embolization of the AVM prior to delivery then resection after delivery. Treatment interventions included: surgical resection (47.6%), radiosurgery (13.6%), embolization (12.6%) and embolization followed by surgical resection (12.6%). Pregnancy was complicated by intrauterine fetal demise (IUFD) in 6 patients (4.5%, n=134) including 4 during the second trimester and 2 during the third trimester. There was no difference in maternal mortality, re-rupture rate or fetal demise between women undergoing treatment of AVM before versus after delivery. There was a decreased risk of AVM residual among women treated after delivery (relative risk 0.71, 95% confidence interval 0.54 – 0.94).

Conclusion : AVM rupture in pregnancy is most common in the second trimester, and surgical resection is the most common AVM treatment. The risks of AVM re-rupture, maternal mortality and IUFD were not affected by treatment timing relative to delivery. Both approaches are reasonable; namely, carrying the mother to fetal viability followed by resection of the AVM or resection of the AVM in the second trimester may be performed safely.