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Outcomes of Pregnancy in Women With Hereditary Hemorrhagic Telangiectasia

de Gussem, Els M. MD; Lausman, Andrea Y. MD, FRCPC; Beder, Aarin J. MD, CFPC; Edwards, Christine P. BSc; Blanker, Marco H. MD, PhD; Terbrugge, Karel G. MD, FRCPC; Mager, Johannes J. MD, PhD; Faughnan, Marie E. MD, MSc

doi: 10.1097/AOG.0000000000000120
Contents: Original Research

OBJECTIVE: To describe pregnancy outcomes in women with hereditary hemorrhagic telangiectasia (HHT).

METHODS: This was a retrospective descriptive study of women with HHT (18–55 years of age) from the Toronto HHT Database using a telephone questionnaire regarding pregnancy, delivery, and neonatal outcomes.

RESULTS: A total of 244 pregnancies were reported in 87 women with HHT. Miscarriages occurred in 20%. Hereditary hemorrhagic telangiectasia–related complications included minor hemoptysis during two pregnancies (1.1%) and hemothorax during four pregnancies (2.1%). One patient presenting with a hemothorax had presented during a previous pregnancy with a transient ischemic attack, most likely resulting from paradoxical emboli. One patient presented with an intracranial hemorrhage, and one patient presented with heart failure. These complications occurred in women previously unscreened and untreated for arteriovenous malformations. Other complications not clearly related to HHT were deep vein thrombosis (n=1), pulmonary embolism (n=1), myocardial infarction (n=1), and myocardial ischemia (n=1). Women noticed an increased frequency of epistaxis and development of new telangiectases during pregnancy. Epidural or spinal anesthesia was performed in 92 of 185 deliveries (50%) without complications. None of these women had undergone screening for spinal arteriovenous malformation before anesthesia.

CONCLUSION: Women with HHT who have not been screened for arteriovenous malformations are at risk for serious pregnancy complications.


Women with hereditary hemorrhagic telangiectasia who have not been screened for arteriovenous malformations are at risk for serious pregnancy complications.Supplemental Digital Content is Available in the Text.

Toronto HHT Centre, Division of Respirology, Department of Medicine, and the Department of Obstetrics & Gynaecology and the Keenan Research Centre and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, the Department of Surgery and Medical Imaging, the University of Toronto Brain Vascular Malformation Study Group, the Toronto Hospital, Western Division, and the Division of Respirology, Department of Medicine, University of Toronto, Toronto, Canada; and the Department of Pulmonology, St. Antonius Hospital, Nieuwegein, and the Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands. Dr. de Gussem is currently affiliated with the Department of Internal Medicine, Faculty of Medicine, University of Manitoba, Winnipeg, Canada.

Corresponding author: Marie E. Faughnan, MD, MSc, St Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada; e-mail:

Funding sources include SWORO (Dutch Foundation for scientific research on HHT) (E.M.d.G.), the Nelson Arthur Hyland Foundation (M.E.F.), the Keenan Research Centre (M.E.F.), and the Li Ka Shing Knowledge Institute (M.E.F.).

The authors thank Elaine Granatstein and Myra Slutsky for assistance in data collection.

Financial Disclosure The authors did not report any potential conflicts of interest.

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal-dominant disorder with a prevalence of one in 5,000–10,000.1 It is also known as Osler-Weber-Rendu syndrome and is caused by a mutation in the Endoglin gene2 or in the Activin A receptor type II-like 1 gene3 in approximately 80% of families.4,5 It is characterized by recurrent epistaxis, mucocutaneous telangiectases, and visceral arteriovenous malformations. Untreated organ arteriovenous malformations can lead to life-threatening hemorrhage, stroke, heart failure, and death.

Knowledge about complications during pregnancy in patients with HHT has increased over the past several years. Initial case series reported life-threatening complications from untreated pulmonary arteriovenous malformations during pregnancy in women with HHT, including massive hemoptysis, spontaneous hemothorax, stroke, and death.6–8 As such, pregnancy has been considered a high-risk period for pulmonary arteriovenous malformation-related complications. Shovlin et al reported life-threatening pulmonary hemorrhage and stroke during pregnancy in 1.4% and 1.2%, respectively, in women with HHT. The majority of this population had not been screened or treated preventatively for arteriovenous malformations.9

Clinicians are also concerned about risk of intracranial hemorrhage from cerebral arteriovenous malformations in patients with HHT and the risk of hemorrhage from a spinal arteriovenous malformation after epidural anesthesia.

The purpose of this study is to describe outcomes of pregnancy in a well-characterized population of patients with HHT with a specific focus on complications of pulmonary arteriovenous malformations and cerebral arteriovenous malformations as well as complications of epidural anesthesia and child outcomes.

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Patients were selected from the Toronto HHT Database of St Michael's Hospital, a tertiary referral center in Toronto, Canada, with an HHT Centre of Excellence. Initial assessment of patients occurred for a wide variety of reasons ranging from a personal major complication to presymptomatic screening after a family member's diagnosis. As such, age at initial assessment as well as clinical symptoms varies widely within our population, like in other reported HHT populations.

A total of 429 women had been assessed for suspected HHT between January 1997 and June 2007. We selected women aged 18–55 years for inclusion in the study.

Women were categorized according to the diagnosis of HHT based on genetic mutation results and the four clinical diagnostic Curaçao criteria10: 1) recurrent spontaneous epistaxis; 2) mucocutaneous telangiectases; 3) visceral telangiectases or arteriovenous malformations; or 4) an affected first-degree relative with HHT. Only women with a definite clinical diagnosis (at least three Curaçao criteria) or a genetic diagnosis of HHT were included.

The study protocol was approved by the St Michael's Hospital research ethics board. All selected women were sent a letter informing them about the study in May–June 2007. Two weeks later they were contacted by telephone by one of two well-trained interviewers (E.M.d.G. and A.J.B.). After informed consent was obtained, a structured telephone questionnaire was administered to obtain their obstetric history, including number of pregnancies, self-reported complications during pregnancy, delivery, the first 6 months postpartum, complications regarding peripartum anesthesia, and neonatal outcomes. Their charts were subsequently reviewed by two persons (E.M.d.G. and C.P.E.) for data regarding screening and treatment of pulmonary, cerebral, or spinal arteriovenous malformations. In the case of women who died, cause of death was recorded from the charts. The current screening protocol for arteriovenous malformations in the Toronto HHT Centre is shown in Appendix 1 (available online at and screening protocol for arteriovenous malformations during pregnancy is described in Appendix 2 (available online at

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Figure 1 shows the patients contacted and included in the study. One hundred fourteen of 213 (54%) women had a definite diagnosis of HHT. Of these, 27 of 114 (24%) (mean age 34.1 years, standard deviation [SD] 9.2) reported no previous pregnancy and 87 of 214 reported a previous pregnancy and were included in the study.

Flow chart of inclusion of women with hereditary hemorrhagic telangiectasia (HHT) from the Toronto HHT Database

Flow chart of inclusion of women with hereditary hemorrhagic telangiectasia (HHT) from the Toronto HHT Database

Clinical characteristics and pregnancy characteristics of women with one or more pregnancy in the past are shown in Table 1 and Table 2, respectively. Complications occurring during pregnancies with live births are shown in Table 3, and severe complications occurring during either pregnancy or postpartum in women with HHT are shown in Table 4.

Table 1

Table 1

Table 2

Table 2

Table 3

Table 3

Table 4

Table 4

None of the four women with pulmonary arteriovenous malformation-related hemothorax during pregnancy had, before pregnancy, been assessed at the HHT Centre or had been screened for pulmonary arteriovenous malformations or even known to have HHT. One patient presenting with a hemothorax had presented during a previous pregnancy with a transient ischemic attack.

Hemoptysis during pregnancy occurred in two HHT cases; both were minor and did not require intervention at the time. One woman was diagnosed and treated for pulmonary arteriovenous malformation 24 years postpartum; the other woman had no significant pulmonary arteriovenous malformations when screened 6 years postpartum.

Two women with HHT had transient ischemic attacks: one during the second trimester and one in the third trimester of her pregnancy. Both women had undiagnosed pulmonary arteriovenous malformations.

Complications during delivery occurred in 10 of 185 (5%) deliveries. The most frequent delivery complication was postpartum uterine hemorrhage requiring surgical intervention (one hysterectomy, three dilatation and curettage) after 4 of 185 (2%) deliveries. Within the first 6 months postpartum, major complications occurred after 6 of 185 (3%) pregnancies.

Vaginal delivery and cesarean delivery were reported for, respectively, 129 of 185 (70%) and 56 of 185 (30%) deliveries. Of the 84 women, 63 (75%) and 21 (25%), respectively, had a vaginal delivery or cesarean delivery for their first pregnancy. Vaginal delivery was denied to six women for eight pregnancies owing to their HHT diagnosis.

Spinal or epidural anesthesia was performed in 92 of 185 (50%) deliveries in women with HHT without prior screening for a spinal arteriovenous malformation, none complicated by an epidural bleed or other serious complications. Only three women underwent magnetic resonance imaging (MRI) screening for spinal arteriovenous malformations before delivery and all were negative. None of these women had spinal or epidural anesthesia after screening.

Mean gestational age was 39.0 (SD 2.2) weeks, and mean gestational age for the first delivery was 39.0 (SD 2.3) weeks as well. Twenty-three of 185 (12%) of children were born prematurely (less than 37 weeks of gestation). Mean birth weight was 3,194 g (SD 562) for all neonates, and mean birth weight after first delivery was 3,178 g (SD 558). Low birth weight (less than 2,500 g) occurred in 18 of 185 (10%) of all neonates.

Eleven of 84 women (13%), three of whom had been treated for pulmonary arteriovenous malformations before, were screened for pulmonary arteriovenous malformations before 13 pregnancies: three with contrast echo alone, four with computed tomography (CT) of the chest only, and six with contrast echo and CT. Screening revealed no pulmonary arteriovenous malformations in five cases, microscopic pulmonary arteriovenous malformations (positive contrast echocardiography but negative CT) in five cases, and a pulmonary arteriovenous malformation was found by CT in three cases, none with a significant feeding artery. Therefore, embolization was not indicated. None of these women required embolization after pregnancy either.

Rescreening at mean of 1 year postpartum was performed after seven pregnancies in which prepregnancy screening demonstrated only nonsignificant pulmonary arteriovenous malformations and none were found to have a significant arteriovenous malformation (feeding artery of at least 3 mm).

Fifteen of 87 women (17%) were screened before or during at least one of their pregnancies for a cerebral arteriovenous malformation by MRI or CT; none had a cerebral arteriovenous malformation.

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Hereditary hemorrhagic telangiectasia often is thought to increase the risk of complications during pregnancy and delivery, although limited published data are available. This is large retrospective descriptive case series of 244 pregnancies in 87 women with HHT. Major complications in the HHT population occurred in 13% of women, all of whom had not been screened or treated for the presence of pulmonary and cerebral arteriovenous malformations before pregnancy. These complications may have been preventable if screening and treatment for pulmonary arteriovenous malformations had been performed before pregnancy. In women screened and treated for the presence of pulmonary arteriovenous malformations and cerebral arteriovenous malformations (13% and 17%, respectively) before pregnancy, no complications occurred.

The incidence of hemothorax in our population is 2.1% (4/185) (95% confidence interval 0.7–5.6%) per pregnancy, which is similar to 1.4% reported by Shovlin et al.9 Transient ischemic attacks and myocardial infarction and ischemia can also be complications from pulmonary arteriovenous malformations resulting from paradoxical emboli. Most complications from pulmonary arteriovenous malformations occurred during the second or third trimester. This is most likely the result of an increased maternal blood volume to approximately 40% and increased cardiac output during pregnancy.11,12 In our series, patients presenting with hemothorax during pregnancy were at risk of poor neonatal outcomes (stillborn neonate, low birth weight) and need for cesarean delivery. Given the survivor bias of our study, we cannot comment on maternal death. The cases of hemothorax and subsequent complications may have been prevented if women had been screened and treated for pulmonary arteriovenous malformations before pregnancy given the effectiveness of embolotherapy.13

The risk of complications from cerebral arteriovenous malformations appears to be low from our data and others and yet some women were advised to have a cesarean delivery because of the diagnosis of HHT and the risk of rupture of a suspected cerebral arteriovenous malformation (even if they were not screened for the presence of a cerebral arteriovenous malformation in advance). The annual risk of hemorrhage from an HHT-related cerebral arteriovenous malformation is estimated at 0.5–1%.14 A previous study in women with sporadic cerebral arteriovenous malformations showed that pregnancy does not increase the risk of a first cerebral hemorrhage from a cerebral arteriovenous malformation,15 but the risk of rebleeding is increased, mainly during the second and third trimesters when the cardiac output and blood volume are increased. Cesarean delivery afforded no better maternal or fetal outcome than vaginal delivery in women with sporadic cerebral arteriovenous malformations.16,17 Treatment decisions for cerebral arteriovenous malformations in patients with HHT should be made on a case-by-case basis with an expert neurovascular team, preferably before pregnancy.18 When cerebral arteriovenous malformations are detected during pregnancy, treatment is generally delayed until the postpartum period.

High-output heart failure is the most common complication of liver vascular malformations in patients with HHT and it is not surprising that it occurs during pregnancy when the cardiac output increases. In the general population of individuals with HHT, the prevalence of liver vascular malformations varies between 41% and 91%19,20 and is associated with a mutation in ACVRL-1 gene in some series.21,22 We speculate that the rarity of high-output heart failure during pregnancy is likely the result of rarity of extensive liver vascular malformations during the typical age range of pregnancy and that liver vascular malformations likely become more diffuse or extensive with advanced age.23

Epistaxis frequency increased during pregnancy in women with HHT, and they were likely to report new telangiectases during pregnancy. These manifestations were not associated with significant complications.

In our clinical experience we have noticed that pregnant women with HHT are increasingly being denied spinal or epidural anesthesia because of concerns regarding puncture of possible spinal arteriovenous malformations. Spinal arteriovenous malformations are present in 0–6% of patients with HHT24,25 and have mostly been reported in children.26,27 There are no published reports of patients with HHT developing complications from epidural anesthesia based on our search of MEDLINE from 1970–2013 using the terms hereditary hemorrhagic telangiectasia, or HHT, or Osler-Weber-Rendu and epidural anesthesia or spinal anesthesia. There are several case reports of women without HHT developing paralysis after puncture of a spinal arteriovenous malformation during regional anesthesia.28,29 There are also several case reports about women without HHT developing symptoms from a spinal arteriovenous malformation during pregnancy with some cases demonstrating spontaneous regression postpartum.30 Spinal arteriovenous malformations in patients with HHT are located in the subarachnoid space of mostly the thoracic spine. Draining veins can be seen at lower levels in the subarachnoid space, exiting along the nerve root, away from the midline. During epidural anesthesia, the subarachnoid space is usually not entered, which most likely explains that to date no complications from spinal arteriovenous malformations have been reported after epidural anesthesia in patients with HHT.9 Screening for the presence of spinal arteriovenous malformations can be offered to patients with HHT, but there is no evidence to date, in the literature or in our series, to support obligatory screening.

There are several potential study limitations that warrant discussion. The study is retrospective and therefore subject to recall bias. This may have affected rates of minor complications (eg, epistaxis), but it is unlikely to have influenced the reporting of life-threatening events such as hemoptysis and heart failure. Volunteer bias is always a concern with this type of study design, which was unlikely to be an issue for our study, because 213 of 271 (79%) of women agreed to be part of the study. Overall, we believe these limitations are of minimal significance and that our results regarding pregnancy and delivery outcomes in women with HHT are meaningful. The strengths of this study are that all aspects of pregnancy are addressed: pregnancy, delivery, anesthesia, postpartum complications, and neonatal outcomes in one population.

Based on our experience and observations, we suggest the following management of women with HHT before and during pregnancy:

  • Pulmonary arteriovenous malformations: prepregnancy screening for the presence of pulmonary arteriovenous malformations and preventive treatment of pulmonary arteriovenous malformations as recommended.18 If not screened before pregnancy, patients are screened and managed for pulmonary arteriovenous malformations according to the “routine screening protocols during pregnancy at Toronto HHT Centre” as mentioned in Appendix 2 (
  • Spinal arteriovenous malformations: screening for the presence of spinal arteriovenous malformations is not routinely recommended given the low incidence of spinal arteriovenous malformations in patients with HHT. However, if screening is being considered, MRI is suggested, ideally prepregnancy. If screening for spinal arteriovenous malformations is considered during pregnancy, although not routinely recommended, this can be done by unenhanced MRI. We routinely recommend consultation with an anesthetist before delivery so that issues can be discussed on a case-by-case basis.
  • Cerebral arteriovenous malformations: prepregnancy screening with MRI of the brain, and if a cerebral arteriovenous malformation is present, management should be decided in consultation with an expert neurovascular team.18 If women have not been screened before pregnancy, screening can be performed during the second or third trimester by MRI or delayed until the early postpartum period. Therapy for a cerebral arteriovenous malformation is generally delayed until after delivery in consultation with an expert neurovascular team. Decisions about delivery should be reached after consultation between the obstetrical and neurovascular teams. In general, asymptomatic women with a cerebral arteriovenous malformation can proceed with vaginal delivery; however, prolonged labor should be avoided and consideration be given to an assisted second stage.

In conclusion, complications during pregnancy and delivery in women with HHT appear to occur mainly in women who have not been screened and treated for arteriovenous malformations before pregnancy. Women with HHT should be screened for pulmonary and cerebral arteriovenous malformations and treated as per International HHT Guidelines, before conception. Preferably, women should be educated about possible pregnancy-related risks before pregnancy. Given that the risk of complications from epidural anesthesia are low, epidural anesthesia should not be withheld on the basis of the diagnosis of HHT, but risks and benefits should be considered on a case-by-case basis.

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