I would like to post on this forum one of the AVM pregnancy studies (see below of the post) and would like to hear back from the members on this forum, If my below findings out of the data of this study is correct.
Based on the characteristics of all 9 Patients with hemorrhage during pregnancy or puerperium this study, they all had some sort of AVM treatment vs. just medical management, while none of the 20% (56 woman) group that didn’t have any treatment (just medical management) out of the 270 woman of the study had any hemorrhage during pregnancy.
Is it fair to say that this study supports somehow that treating an AVM may be a greater risk for pregnancy?
There appears to be a five-fold increase in risk of rupture during pregnancy or puerperium, though this differs from a larger study of Chinese-only subjects. The two studies do seem to correlate with those referred to by Jonny. Personally, this feels like it makes sense: the study underpins what we might expect.
The choice as to “medical management” v intervention was driven by the Spetzler-Martin scale rather than anything else: this is, after all, a retrospective analysis.
There is a risk that the study is not wholly reflective of society as a whole for a number of reasons but in particular because some people will choose to avoid pregnancy until their AVM has been obliterated. I guess that might mean that the risk is higher if everyone were to pursue a pregnancy irrespective of their brain AVM.
Trying to determine some statistical trend from 270 patients is possible but trying to read some trend from 9 patients is not.
I don’t think it is in any way reasonable to infer from the study that avoiding intervention that would otherwise be recommended gives better outcomes. I’d say the reason that the small group who were on medical management were in that situation was probably because the assessment of their AVM was grade V or VI and therefore liable to lead to significant deficits if treated. What causes AVMs to go on to bleed is what you’d need to understand and whether deeply embedded AVMs tend to last longer anyway before bleeding than others.
If you are trying to compare with yourself, the question might be which group do you statistically align with, not which one would you like to align with.
It’s not only a trend from 9 patients, it’s the 56 patients that didn’t rupture and that all that did rupture (regardless of how many out of 270) were treated on way or another.
These are the two studies that I referred to. The article you posted also refers to the Chinese study.
The study you found indicated that those women who were undergoing “medical management” all had AVMs that were Spetzler-Martin grades V or VI – i.e. would be expected to result in some deficits if they were operated on. So, the choice as to whether to operate or not was driven by that high score.
And as for the ARUBA study, I have previously read both the ARUBA study and it’s rebuttal. My conclusion of those two is that it remains perfectly unclear whether intervention or avoidance of intervention can be shown statistically to be significant. It is by no means these days a new study and capabilities have much improved in the intervening 12 years.
I don’t believe there is anything upon which we can place good reliance to tell us that intervention mode A, B, or C gives better outcomes or that abstention gives better outcomes.
I don’t think we can make assumptions as to reason that the small group who were on medical management, each one has it’s own reasons.
I didn’t find any concrete studies as as to what causes AVMs to go on to bleed, I believe there are much more variables to the list you stated, if those are even the causes by all people at all, if you have concrete literature on this, I would be very happy to see them.
After all the facts of the study speaks about themself and you even made it stronger by claiming that the group who did medical treatment maybe be much more prone to bleeds, that gives us a very clear indication that treatments may increase the risk more than an untreated AVM.
Again, I don’t think that it’s fair to claim that the groups that were treated were graded with lower SM Grade AVM and the ones not treated were graded with a higher SM grade, as there are patients that just decided to do medical management, some maybe pre treatment or the beginning stages of Gamma Knife or even a higher Grade
I read the whole of the study you posted. I will try to find the text that says that the women who were not treated were because the grading was SM 5 or 6. I’m not bringing my judgement into this at all: just trying to find facts in the study in the same way as you are. Honestly!
I think I’ve mixed a few factlets together in what I said above! I am struggling to read the whole study again: I really don’t have the patience and the absence of a search facility when reading PDFs doesn’t help.
I think your aim really is to question whether you should avoid treatment and prefer to follow conservative management and you were asking if we can infer from this study that it reinforces the ARUBA findings that conservative management gives at least as good results.
I don’t believe that you can use this study to reinforce that view. It shows that of 270 women, 149 had a rupture and 9 of those had their rupture during their pregnancy. Using the maths in the study, it showed that an above average number of ladies had their rupture during their pregnancy or puerperium and therefore there is an increased risk of rupture during pregnancy.
Having read the rebuttal of the ARUBA study several years ago, my conclusion at the time was that it was perfectly unclear whether conservative management gave better outcomes than intervention because the views of the doctors was that the only way to definitively do so was to do a double blind trial (and that is very difficult morally to do when the trial outcomes will include serious disability or death) and I struggle to believe that you can read into this study the objective that I think you have.
The one piece I did find towards what I talked about (but I do think I’ve merged other thoughts in my mind when discussing it above) is that the trial notes that Spetzler Martin Grade 5 or 6 are regularly managed conservatively
So it is difficult to infer proactive steps to take, especially for these patients but on re-reading, there were 56 patients who were being managed conservatively and only 19 with grade 5 AVMs. I am unclear what proportion of the 56 were in or out of the 149. It may well be there are complexities in lower graded AVMs that was promoting the doctors or their patients towards conservative management. So you’re right: grading was not the only factor.
The other thing I want to say is that I don’t ever want anyone to read from anything that I say that intervention is the way forwards. It isn’t. You have to be comfortable for yourself whether treatment of whichever modality is for you or whether abstention, conservative management is right and our doctors will give advice to treat or not to treat. I simply have the view, mostly from reading the ARUBA trial and its rebuttal that there is no nice statistical evidence that helps us to decide whether one route is better than the other.
It is real fork-in-the-road stuff to decide which route to take. It would be great if it were clearer which way was safest.
I think you missed my point and maybe becuase I wasn’t clear enough. We decided no matter what, the risk of intervention outweighs the benefit of it, and therefore we decided on conservative management, my question is if we can learn from this study that intervention may increase the risk while being pregnancy or not which then supports another reason the decision of conversation management.
Understood. I was not clear what you were trying to get to.
The yellow highlighted text I took to be to do with trying to do a resection during pregnancy and part of the reason why it isn’t advised is in the blue highlight: i.e. you wouldn’t normally choose to do a resection for grade 5 and 6 patients. But that is only part of the reasoning.
I think we’d need to find reference 1 to understand the full set of reasons for and against:
I don’t tend to believe that intervention itself increases the risk during pregnancy: that this is what that text is saying. I feel it is saying it is perhaps similar: 50:50.
I believe this study is only concluding that the risk of rupture is higher during pregnancy than through the rest of middle life. What isn’t clear from this study is how resolved the patients’ AVMs were at the point of pregnancy. There are a large number of patients who had been treated with radiotherapy: had they had the chance for that radiotherapy to do all of its work prior to falling pregnant? I don’t think it is clear. Other modes are more immediate, so may be less of a factor but these things are not the focus of the study, hence not discussed.
I meant to point out the 50:50 to show that even research doesn’t prove that intervention is decreasing the risk and as to the pregnancy risk rate vs. decreasing the risk rate in other times or just decreasing symptoms. The reason I’m pointing out is that even if given the higher risk of bleed while in pregnancy would be convincing towards intervention, the fact that it’s 50:50 and the fact that all 9 patients were treated is not rebutting that convincement’s. I know that the study is not geared to that findings, but the data of the study still proves my point I believe.
I see what you’re saying but I don’t think it proves anything. It feels like you want that to be the answer, so you’re looking for things to back that position up.
Find the reference and let’s see what the reasons are that are set out why intervention early in pregnancy is not clearly helpful. It may be to do with impact on the baby as much as on the mum. It’s not good to guess at these things.
Nothing is really proving anything, but it at least dosn’t encourage or give weight towards intervention. I’m talking about intervention before pregnancy not in early pregnancy.
