脑动静脉畸形急性出血或既往出血的妊娠患者临床特征、治疗及结局观察

doi:10.3969/j.issn.1673-5765.2025.06.010

摘要/Abstract

摘要： 目的研究脑动静脉畸形（arteriovenous malformation，AVM）急性出血或既往出血的妊娠患者的临床特征、干预时机、干预方式及母婴预后。
方法本研究回顾性纳入2010年1月—2021年12月首都医科大学附属北京天坛医院AVM急性出血的妊娠患者，另外纳入本次妊娠期间无出血，但既往有AVM出血并在干预治疗后仍有畸形残留的患者作为比较。采集年龄，妊娠/分娩信息（既往孕产史、发病/分娩孕周、分娩方式、合并基础疾病及妊娠期合并症），入院症状，AVM相关信息（Spetzler-Martin分级、位置、出血部位等），妊娠前、妊娠期、产褥期治疗情况及母婴预后（产妇使用mRS评分评估，新生儿使用Apgar评分评估）等信息。
结果共纳入18例患者，其中AVM急性出血的妊娠患者12例，AVM既往出血的妊娠患者6例。18例患者的年龄范围为23～34岁，年龄中位数为29.0（27.5～31.0）岁。发病及分娩孕周中位数分别为22.0（16.5～30.0）周和32.0（28.0～36.0）周。其中，Spetzler-Martin分级Ⅳ～Ⅴ级占比最高（44.4%，8/18），幕上畸形占比83.3%（15/18）。12例AVM急性出血的妊娠患者中83.3%（10/12）的出血发生于妊娠中晚期（孕周≥13周），急诊AVM外科治疗的产妇预后良好率为75.0%（6/8），新生儿预后良好率为75.0%（6/8）；保守观察的产妇预后良好率为75.0%（3/4），新生儿预后良好率为50.0%（2/4）。剖宫产的产妇预后良好率为88.9%（8/9），新生儿预后良好率为88.9%（8/9）；人工流产的产妇预后良好率为33.3%（1/3）。AVM既往出血的妊娠患者采取保守观察的产妇预后良好率为83.3%（5/6），新生儿预后良好率为83.3%（5/6）。剖宫产5例（产妇3例、新生儿4例预后良好），人工流产1例（产妇预后良好，胎儿死亡）。
结论妊娠期脑AVM急性出血多发生在妊娠中晚期，建议多学科评估后积极进行神经外科干预。对于AVM既往出血的妊娠患者，做好围产期多学科评估后，可考虑对AVM采取保守观察，建议分娩方式为剖宫产。

文章导读： 本研究通过对脑动静脉畸形急性出血和既往出血的妊娠期患者进行总结分析显示，妊娠期脑动静脉畸形急性出血高发于妊娠中晚期，积极的神经外科干预可能改善母婴结局；对既往出血者采取保守观察的母婴结局相对良好。

关键词: 脑动静脉畸形; 颅内出血; 妊娠期; 母婴预后

Abstract: Objective To investigate the clinical characteristics, intervention timing, intervention methods, and maternal-neonatal outcomes in pregnant patients with acute or previous hemorrhage from cerebral arteriovenous malformation (AVM).
Methods This study retrospectively included pregnant patients with acute AVM hemorrhage treated at Beijing Tiantan Hospital, Capital Medical University from January 2010 to December 2021. Additionally, pregnant patients without hemorrhage during the current pregnancy but with a history of AVM hemorrhage and residual malformations after interventional treatment were included for comparison. Collected information included age, pregnancy/delivery details (obstetric history, gestational weeks at symptom onset/delivery, delivery mode, underlying diseases, and pregnancy complications), admission symptoms, AVM-related characteristics (Spetzler-Martin grade, location, bleeding site), treatment details (pre-pregnancy, during pregnancy, and puerperium), and maternal-neonatal outcomes (maternal outcomes assessed using the mRS score, neonatal outcomes assessed using the Apgar score).
Results A total of 18 patients were enrolled, including 12 pregnant patients with acute AVM hemorrhage and 6 pregnant patients with previous AVM hemorrhage. The age range of the 18 patients was 23-34 years, with a median age of 29.0 (27.5-31.0) years. The median gestational weeks at symptom onset and delivery were 22.0 (16.5-30.0) weeks and 32.0 (28.0-36.0) weeks, respectively. The Spetzler-Martin grading showed that grades IV-V accounted for the highest proportion (44.4%, 8/18), supratentorial malformations accounted for 83.3% (15/18). Among the 12 pregnant patients with acute AVM hemorrhage, 83.3% (10/12) experienced hemorrhage during the mid-to-late trimester of pregnancy (gestational weeks≥13 weeks). For patients receiving emergency AVM surgical treatment, the maternal favorable outcome rate was 75.0% (6/8), and the neonatal favorable outcome rate was 75.0% (6/8). For patients receiving conservative management, the maternal favorable outcome rate was 75.0% (3/4), and the neonatal favorable outcome rate was 50.0% (2/4). For patients delivered via cesarean section, the maternal favorable outcome rate was 88.9% (8/9), and the neonatal favorable outcome rate was 88.9% (8/9). For patients undergoing artificial abortion, the maternal favorable outcome rate was 33.3% (1/3). For pregnant patients with previous AVM hemorrhage receiving conservative management, the maternal favorable outcome rate was 83.3% (5/6), and the neonatal favorable outcome rate was 83.3% (5/6). Cesarean section was performed in 5 cases (maternal favorable outcome in 3 cases, neonatal favorable outcome in 4 cases), artificial abortion was performed in 1 case (maternal favorable outcome, neonatal death).
Conclusions Acute hemorrhage in pregnant patients with cerebral AVMs predominantly occurs in the mid-to-late trimester. Proactive neurosurgical intervention after multidisciplinary evaluation is recommended. For pregnant patients with previous AVM hemorrhage, conservative management of AVM with multidisciplinary perinatal assessment is feasible, and cesarean section is recommended as the delivery mode.

Key words: Cerebral arteriovenous malformation; Intracranial hemorrhage; Gestational period; Maternal-neonatal outcome

中图分类号:

刘通, 尹子晗, 张中基, 张岩, 刘兴炬. 脑动静脉畸形急性出血或既往出血的妊娠患者临床特征、治疗及结局观察[J]. 中国卒中杂志, 2025, 20(6): 746-752.

LIU Tong, YIN Zihan, ZHANG Zhongji, ZHANG Yan, LIU Xingju. Observation on Clinical Characteristics, Treatment, and Outcomes in Pregnant Patients with Acute or Previous Hemorrhage from Cerebral Arteriovenous Malformations[J]. Chinese Journal of Stroke, 2025, 20(6): 746-752.

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