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Cerebral Cavernous Malformations and Pregnancy: Hemorrhage Risk and Influence on Obstetrical Management

Witiw, Christopher D. BSc*; Abou-Hamden, Amal MBBS; Kulkarni, Abhaya V. MD, PhD§; Silvaggio, Joseph A. MD; Schneider, Carol MD; Wallace, M. Christopher MD, MSc#

doi: 10.1227/NEU.0b013e31825fd0dc
Research-Human-Clinical Studies

BACKGROUND: Cerebral cavernous malformations are brain vascular malformations associated with intracranial hemorrhage. It is unclear whether pregnancy is a risk factor for hemorrhage, yet there is speculation that it may be.

OBJECTIVE: To compare the risk of clinically significant hemorrhage during pregnancy and nonpregnancy.

METHODS: A total of 186 patients from the University of Toronto Vascular Malformations Study Group were enrolled. The obstetrical history of each patient was collected and matched to their neurological history from the records of the study group. All hemorrhagic events occurring during childbearing years were associated with either a defined pregnancy risk period or nonpregnancy period. Patients were also asked to recall advice that they received from health care professionals regarding risk of hemorrhage in pregnancy.

RESULTS: Among our patient population there were 349 pregnancies (283 live births) and 49 hemorrhages during childbearing years, 3 of which were during pregnancy but none during delivery or within 6 weeks post partum. The hemorrhage rate for pregnant women was 1.15% (95% confidence interval: 0.23-3.35) per person-year and 1.01% (95% confidence interval: 0.75-1.36) per person-year for nonpregnant women. Relative risk of pregnancy was 1.13 (95% confidence interval: 0.34-3.75) (P = .84). Neurosurgeons and obstetricians were the source of most hemorrhage risk advice. The majority of neurosurgeons suggested that the risk was unchanged, but the obstetricians were divided. Four patients never conceived, and 2 others began contraception because of the advice that they received.

CONCLUSION: The risk of intracranial hemorrhage from cerebral cavernous malformations is likely not changed during pregnancy, delivery, or post partum.

ABBREVIATIONS: CCM, cerebral cavernous malformation

CI, confidence interval

*School of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada

Division of Neurosurgery, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada

§Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada

Section of Neurosurgery, Department of Surgery, Health Sciences Centre, University of Manitoba, Winnipeg, Manitoba, Canada

Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Manitoba, Winnipeg, Manitoba, Canada

#Division of Neurosurgery, Department of Surgery, Queen's University, Kingston General Hospital, Kingston, Ontario, Canada

Correspondence: M. Christopher Wallace, MD, MSc, Division of Neurosurgery, Department of Surgery, Queen's University, Kingston General Hospital, Kingston, Ontario, Canada K7L 2V7. E-mail:

Received October 3, 2011

Accepted May 2, 2012

Copyright © by the Congress of Neurological Surgeons