腦動(dòng)靜脈畸形（AVM）破裂出血已知的危險(xiǎn)因素有既往出血，深靜脈引流和部位深等。而妊娠一直以來(lái)是神經(jīng)外科醫(yī)生假定的一個(gè)重要危險(xiǎn)因素，近期發(fā)表在《神經(jīng)外科學(xué)》支持這一推測(cè)。該研究表明，對(duì)于顱內(nèi)動(dòng)靜脈畸形的患者，懷孕的婦女在妊娠期間發(fā)生血管破裂和出血的危險(xiǎn)，比未懷孕的婦女明顯高出8%。

　　該研究主要研究者哈佛醫(yī)學(xué)院的專家 Bradley A. Gross博士和 Rose Du博士回顧了通過(guò)血管造影診斷動(dòng)靜脈畸形的54名婦女的病例資料。年出血率為隨訪中每年出血的病人數(shù)與病人總數(shù)之比。隨訪的患者年的計(jì)算是假定從出生病灶即存在直到AVM閉塞。將妊娠期出血Cox比例風(fēng)險(xiǎn)模型作為事件依賴性變量用來(lái)計(jì)算風(fēng)險(xiǎn)比。

　　研究結(jié)果發(fā)現(xiàn)在62懷孕中出現(xiàn)5次出血，每次懷孕出血的發(fā)生率為8.1％，而每年出血發(fā)生率為10.8%。在隨訪的2461.3患者年中，有28例出血發(fā)生，平均每年有1.1％出血率。妊娠期間出血的風(fēng)險(xiǎn)與未妊娠婦女相比，高出7.91倍（P =2.23×10），而40歲以上的AVM患者，這一比例則提高到18.12（P =7.31×10）。

　　盡管該研究研究的病例數(shù)較少，但其結(jié)果強(qiáng)烈提示AVM患者在妊娠期有明顯更高的出血風(fēng)險(xiǎn)。在發(fā)生的四例AVM出血事件，在妊娠第22周到第39周發(fā)生突然頭痛和其他的癥狀。盡管經(jīng)過(guò)及時(shí)的治療患者及胎兒均存活下來(lái)，但其中一位母親還是落下了終身殘疾。

　　基于以上研究的結(jié)論，研究有如下推薦：

　　對(duì)于那些希望生育的AVM患者，應(yīng)及早進(jìn)行干預(yù)治療，特別是既往已有AVM出血的患者。

　　對(duì)于在妊娠期間新發(fā)現(xiàn)AVM的患者。若AVM已破裂，需早期干預(yù)；如果未破裂的AVM，建議進(jìn)行綜合評(píng)估，權(quán)衡干預(yù)和不干預(yù)對(duì)于繼續(xù)妊娠的風(fēng)險(xiǎn)。

　　專家組推薦以剖宮產(chǎn)的方式分娩，并指出醫(yī)務(wù)人員或醫(yī)療機(jī)構(gòu)亦可建議不同的分娩方式。

　　總之，專家表示希望他們的發(fā)現(xiàn)和建議將引起人們的思考，并希望那些已知患有AVM但并未治療的婦女在計(jì)劃妊娠的事情上更加謹(jǐn)慎。

　　Hemorrhage from arteriovenous malformations during pregnancy.

　　Gross BA, Du R.

　　Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts 02115, USA.

　　Abstract

　　BACKGROUND:

　　Previous hemorrhage, deep venous drainage, and deep location are established risk factors for arteriovenous malformation (AVM) hemorrhage. Although pregnancy is an assumed risk factor, there is a relative paucity of data to support this neurosurgical tenet.

　　OBJECTIVE:

　　To elucidate the hemorrhage rate of AVMs during pregnancy.

　　METHODS:

　　We reviewed the records of 54 women with an angiographic diagnosis of an AVM at our institution. Annual hemorrhage rates were calculated as the ratio of the number of bleeds to total number of patient-years of follow-up. Patient-years of follow-up were tallied assuming lesion presence from birth until AVM obliteration. The Cox proportional hazards model for hemorrhage with pregnancy as the time-dependent variable was used to calculate the hazard ratio.

　　RESULTS:

　　Five hemorrhages in 4 patients occurred over 62 pregnancies, yielding a hemorrhage rate of 8.1% per pregnancy or 10.8% per year. Over the remaining 2461.3 patient-years of follow-up, only 28 hemorrhages occurred, yielding an annual hemorrhage rate of 1.1%. The hazard ratio for hemorrhage during pregnancy was 7.91 (P = 2.23 × 10(-4)), increasing to 18.12 (P = 7.31 × 10(-5)) when limiting the analysis to patient follow-up up to age 40.

　　CONCLUSION:

　　Because of the increased risk of hemorrhage from AVMs during pregnancy, we recommend intervention in women who desire to bear children, particularly if the AVM has bled. If the AVM is discovered during pregnancy, we recommend early intervention if it has ruptured; if it is unruptured, we recommend comprehensive counseling, weighing risks of intervention against continuation of pregnancy without intervention.