International Journal of Gynecology and Obstetrics 125 (2014) 150–153

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CLINICAL ARTICLE

Intracranial hemorrhage from moyamoya disease during pregnancy and puerperium Xing-Ju Liu, Dong Zhang, Shuo Wang, Yuan-li Zhao, Xun Ye, Wang Rong, Cao Yong, Shuai Kang, Ji-Zong Zhao ⁎ Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China

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Article history: Received 31 July 2013 Received in revised form 4 October 2013 Accepted 22 January 2014 Keywords: Intracranial hemorrhage Moyamoya disease Pregnancy Puerperium

a b s t r a c t Objective: To determine the incidence of hemorrhage among women with moyamoya disease (MMD) during pregnancy and puerperium. Methods: Data were assessed from patients with MMD who were referred to Beijing Tiantan Hospital between January 1985 and December 2012. Women aged 18–40 years with known parturient status were included. Annual hemorrhage rates were calculated as the ratio of number of bleeds to total number of patient-years of follow-up. Results: There were 184 patients with MMD. Ninety-six women were 18–40 years, and 81 had known parturient status. Among the 184 patients, 203 hemorrhages occurred during 5642 patientyears of follow-up. The annual hemorrhage rate was 3.6% overall, and 3.9% among 96 female patients (P N 0.05). Among the 81 patients with known parturient status, 4 hemorrhages occurred during pregnancy and puerperium among 144 pregnancies (hemorrhage rate, 2.8% per pregnancy; 3.2% per year). Among the remaining 77 patients, 86 hemorrhages occurred during 2574 patient-years of follow-up (annual hemorrhage rate, 3.3%). The risk of hemorrhage from MMD was not increased during pregnancy and puerperium (hazard ratio, 0.73; 95% confidence interval, 0.23–2.35; P = 0.60). Conclusion: Pregnancy and puerperium are not risk factors for intracranial hemorrhage in hemorrhagic MMD. There is no need to advise patients against pregnancy. Crown Copyright © 2014 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics. All rights reserved.

1. Introduction Intracranial hemorrhage is a serious complication during pregnancy and puerperium. Although uncommon, it has a substantial maternal mortality of 35%–83% [1–3]. Rupture of MMD vessels during pregnancy and puerperium is relatively rare, especially in Europe and the United States, where there is a low prevalence of MMD. Recently, increasing numbers of young women of childbearing age have been diagnosed with MMD. Most of them do not receive treatment until the initial bleeding occurs, and some patients have experienced events during pregnancy and puerperium [4–8]. However, risk factors for bleeding among patients of MMD have not yet been established. To our knowledge, no data are available on the risk of intracranial hemorrhage resulting from MMD associated with pregnancy or puerperium. The aim of the current study was to present data from a series of female patients with hemorrhagic MMD and to use these data to calculate hemorrhage rates, and the risk of hemorrhage, during pregnancy and puerperium. 2. Materials and methods In a retrospective study, data were analyzed from a collected database of 184 patients with hemorrhagic MMD who were referred to ⁎ Corresponding author at: Beijing Tiantan Hospital, Capital Medical University, No. 6 Tiantan Xili, Chongwen District, Beijing, 100050, China. Tel./fax: +86 10 67096523. E-mail address: [email protected] (J.-Z. Zhao).

Beijing Tiantan Hospital, Beijing, China, between January 1, 1985, and December 31, 2012. The study was approved by the Beijing Tiantan Hospital Research Ethics Committee and informed consent was obtained from each patient. The diagnostic criteria for hemorrhagic MMD were based on the following guidelines reported by Fukui et al. [9] in 1997. First, the presence of stenosis or occlusion of the terminal internal carotid and the proximal middle and anterior cerebral arteries, as confirmed by digital subtraction angiography or magnetic resonance angiography. Second, unilateral or bilateral involvement. Third, a primary symptom of intracranial hemorrhage, as verified by cerebral computed tomography (CT) scan. Patients with any other disease that might explain the arterial steno-occlusion were not diagnosed with MMD. The inclusion criteria for the present analysis were female patients with hemorrhagic MMD who were aged from 18 to 40 years (because 99% of pregnancies occur among women in this age range in China). The exclusion criteria were patients whose initial symptoms were caused by ischemia. Patients who received revascularization before pregnancy were also excluded in order to eliminate any effects of this therapy (Fig. 1). Information was collected on the number of children born. For patients with intracranial hemorrhage during pregnancy and puerperium, information was retrieved on maternal age, parity, gestational age, and Glasgow Outcome Scale (GOS) scores at admission, modes of delivery, methods of treatment, and maternal and fetal outcome. Maternal outcome was categorized according to the 5-point GOS. Fetal outcome was categorized according to the Apgar score on delivery at 1–5 minutes

0020-7292/$ – see front matter. Crown Copyright © 2014 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2013.10.020

X.-J. Liu et al. / International Journal of Gynecology and Obstetrics 125 (2014) 150–153

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Patients screened (n=184)

Male patients excluded (n=79)

Female patients (n=105)

Female patients excluded (n=9) Age >40 y (n=6) Age

Intracranial hemorrhage from moyamoya disease during pregnancy and puerperium.

To determine the incidence of hemorrhage among women with moyamoya disease (MMD) during pregnancy and puerperium...
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