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Original research
Risk of intracranial hemorrhage associated with pregnancy in women with cerebral arteriovenous malformations
  1. Songmi Lee1,
  2. Youngran Kim1,
  3. Babak B Navi2,
  4. Rania Abdelkhaleq1,
  5. Sergio Salazar-Marioni1,
  6. Spiros L Blackburn3,4,
  7. Arvind B Bambhroliya5,
  8. Victor Lopez-Rivera1,
  9. Farhaan Vahidy6,
  10. Sean I Savitz1,4,
  11. Annika Medhus1,
  12. Hooman Kamel2,
  13. James C Grotta7,
  14. Louise McCullough1,
  15. Peng Roc Chen3,4,
  16. Sunil A Sheth1,4
  1. 1 Neurology, UTHealth McGovern Medical School, Houston, Texas, USA
  2. 2 Neurology, Weill Cornell Medical College, New York City, New York, USA
  3. 3 Neurosurgery, UTHealth McGovern Medical School, Houston, TX, USA
  4. 4 Institute for Stroke and Cerebrovascular Disease, UTHealth McGovern Medical School, Houston, TX, USA
  5. 5 University of Texas School of Public Health, Houston, Texas, USA
  6. 6 Center for Outcomes Research, Houston Methodist, Houston, Texas, USA
  7. 7 Stroke Research and Mobile Stroke Unit, Memorial Hermann Hospital-Texas Medical Center, Houston, TX, USA
  1. Correspondence to Dr Sunil A Sheth, Neurology, University of Texas McGovern Medical School, Houston, TX 77030, USA; ssheth{at}


Background Prior studies on rupture risk of brain arteriovenous malformations (AVMs) in women undergoing pregnancy and delivery have reported conflicting findings, but also have not accounted for AVM morphology and heterogeneity. Here, we assess the association between pregnancy and the risk of intracranial hemorrhage (ICH) in women with AVMs using a cohort-crossover design in which each woman serves as her own control.

Methods Women who underwent pregnancy and delivery were identified using DRG codes from the Healthcare Cost and Utilization Project State Inpatient Databases for California (2005–2011), Florida (2005–2014), and New York (2005–2014). The presence of AVM and ICH was determined using ICD 9 codes. Pregnancy was defined as the 40 weeks prior to delivery, and postpartum as 12 weeks after. We defined a non-exposure control period as a 52-week period prior to pregnancy. The relative risks of ICH during pregnancy were compared against the non-exposure period using conditional Poisson regression.

Results Among 4 022 811 women identified with an eligible delivery hospitalization (median age, 28 years; 7.3% with gestational diabetes; 4.5% with preeclampsia/eclampsia), 568 (0.014%) had an AVM. The rates of ICH during pregnancy and puerperium were 6355.4 (95% CI 4279.4 to 8431.5) and 14.4 (95% CI 13.3 to 15.6) per 100 000 person-years for women with and without AVM, respectively. In cohort-crossover analysis, in women with AVMs the risk of ICH increased 3.27-fold (RR, 95% CI 1.67 to 6.43) during pregnancy and puerperium compared with a non-pregnant period.

Conclusions Among women with AVM, pregnancy and puerperium were associated with a greater than 3-fold risk of ICH.

  • arteriovenous malformation
  • hemorrhage
  • congenital
  • stroke
  • vascular malformation

Data availability statement

Data are available in a public, open access repository. Data are publicly available at the Healthcare Cost and Utilization Project (HCUP) website.

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Data availability statement

Data are available in a public, open access repository. Data are publicly available at the Healthcare Cost and Utilization Project (HCUP) website.

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  • SL and YK contributed equally.

  • Contributors SL, YK, ABB, FV, AM, SAS: conceived, designed, analyzed data, helped prepare drafts, and gave final approval of the manuscript. Remaining authors: interpreted data, revised manuscript, and approved the final manuscript.

  • Funding SAS reports funding from the American Academy of Neurology and the National Institutes of Health. SLB has effort supported through an NIH K23 grant

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.