313 - Ruptured Arteriovenous Malformation In Pregnancy: A Case Report

Case Diagnosis: Ruptured arteriovenous malformation in pregnancy

Case Description: A 34-year-old G1P0 15-week pregnant female with history of deep vein thrombosis at 12-weeks gestation on enoxaparin was found having a 15-minute generalized tonic-clonic seizure by her husband. Imaging revealed right intracerebral hemorrhage secondary to ruptured arteriovenous malformation (AVM). Right decompressive hemicraniectomy and left frontal external ventricular drain placement were performed followed by embolization and resection of a right frontal and insular AVM. Her course was complicated by Klebsiella pneumonia treated with cefepime and central fevers managed with bromocriptine.

She was admitted to inpatient rehabilitation for left-sided hemiplegia with spasticity, right-sided gaze, and oropharyngeal dysphagia. Bromocriptine was continued for neurostimulation and weaned as her cognition improved. Fetal monitoring was performed throughout the admission, and anti-Xa levels were followed weekly given changes in enoxaparin metabolism throughout pregnancy. By discharge, she had significant improvement of her function and tolerated a regular diet with thin liquids. She was discharged for a planned cranioplasty.

Discussions: Studies suggest the risk of hemorrhage from intracranial AVMs may be higher during pregnancy, especially later in gestation and with prior hemorrhages. Conservative management or definitive treatment prior to conception is generally preferred for unruptured AVM’s. Elective procedures are typically deferred until after delivery unless the risk of hemorrhage is high. In the case of ruptured AVM during pregnancy, intervention depends on the gestational age. At < 34 weeks, intervention is recommended within 2 weeks. While at ≥34 weeks, expedited delivery followed by AVM intervention is often considered, if feasible. Neonatal outcomes are generally favorable with no significant difference in infants born to mothers with and without AVM hemorrhage.

Conclusions: This case highlights a complex scenario of an AVM rupture in a pregnant patient. She was successfully managed in the hospital and had great recovery in rehabilitation prior to her cranioplasty.