Viktor Szeder, MD, PhD, MSc, FSVIN, is an associate clinical professor of radiology and neurosurgery and the director of the Fellowship Training Program in the Division of Interventional Neuroradiology at the David Geffen School of Medicine at UCLA in Los Angeles, California.

David Kimball, MD, is an interventional neuroradiology fellow in the Division of Interventional Neuroradiology at the David Geffen School of Medicine at UCLA in Los Angeles, California.

Brain arteriovenous malformations (AVMs) are one of several vascular malformations that occur within the brain. Unlike most other such deformities, brain AVMs are particularly dangerous because their rupture can lead to intracranial hemorrhage. Patients who present with unruptured brain AVMs can have a variety of neurologic symptoms, including headaches, seizures, and stroke-like symptoms. A diagnosis of AVM poses many challenges for obstetricians and pregnant patients alike. In this article, we hope to demystify the disorder and guide clinicians through the management of these relatively uncommon lesions.

Brain AVMs are connections between arteries and veins that lack an intervening capillary network. They shunt blood directly from the high-pressure arterial system to low-pressure veins, which are not designed to withstand such a high and forceful flow. In general, an AVM contains a central nidus that appears as a tangle of serpiginous blood vessels, usually in the center of the lesion (

). Importantly, there is no normal intervening brain tissue within the AVM nidus (

In addition, AVMs can possess other characteristics that put them at an increased risk for hemorrhage, including intranidal or perinidal aneurysms. These aneurysms can be prone to rupture and lack an intervening nidus. In addition, venous outflow restrictions or venous dilatations can place particular strain on otherwise normal, relatively thin veins, which also put AVMs at a higher risk of rupture.

The pathogenesis and pathology of brain AVMs are poorly understood. A debate exists as to whether they are congenital or acquired. They have historically been classified as congenital, although there is an increasing number of reports of de novo cases, which add weight to the notion that these are dynamic lesions that can form postnatally.

Brain AVMs are relatively uncommon, occurring in approximately 0.1% of the population, which is one-tenth the incidence of brain aneurysms.

 Initial presenting symptoms can range from new onset of headaches or any number of other focal neurologic signs. The prevalence of general headache in pregnant women has been described to be as high as 35% and is extremely nonspecific.

 A nonsevere headache without an abrupt onset (eg, a headache that is not “thunderclap”) is generally not worrisome. 

However, any new onset headache, particularly those that present with transient neurological symptoms during pregnancy, do require appropriate management and workup to rule out serious intracranial pathology.

Several classification schemes have been proposed for the grading of brain AVMs, but the most widely used is Spetzler-Martin,

 which assigns points in 3 categories: AVM size, location (in eloquent cortex such as the motor strip), and venous outflow anatomy (

Grades range from 1 (most “benign”) to 5 (most “aggressive”). The scale was initially developed as a tool to predict outcomes after surgical resection: a Spetzler-Martin grade 1 AVM could be easily resected, and a grade 5 AVM was considered inoperable. However, the grading scheme has been extrapolated upon and has been applied to other treatment modalities, such as radio or endovascular therapy.

The most feared complication of a brain AVM is rupture leading to intracranial hemorrhage. The mortality rate after intracranial hemorrhage from AVM rupture in all patients ranges from 12% to 67%, and 23% to 40% of survivors subsequently experience significant disability.

In pregnant women, cerebral AVM bleeding has been associated with a 28% rate of maternal mortality, a 14% rate of fetal mortality, and with miscarriage in early pregnancy (presumably from the poor maternal prognosis, which generally requires an extended stay in an intensive care unit).

 It has been reported that most cerebral AVM hemorrhages occur between 20 weeks of gestation and 6 weeks postpartum,9 which coincides with maternal hemodynamic changes.

Dramatic physiologic changes occur in pregnancy. Plasma volume increases by 40% to 50% and red blood cell volume by 20% to 30%. There is also increased cardiac output, body weight, and rate of thrombosis. It may be reasonable to conclude that the risk of AVM rupture during pregnancy increases owing to these changes. However, there is no agreement in the literature about the risk of AVM rupture during pregnancy, with several studies suggesting that there is no connection between the two.

Liu et alshowed no increased risk of hemorrhage in patients with cerebral AVM during pregnancy and puerperium.

 Horton et alshowed that pregnant patients with brain AVM face a 3.5% risk of hemorrhage during pregnancy, which is not an increase compared to nonpregnant patients.

Other studies cite a slightly increased risk of hemorrhage during pregnancy.

 For example, Porras et al demonstrated an annual hemorrhage rate of 1.3% in nonpregnant women versus 5.7% in pregnant women.

 Similarly, a recent meta-analysis showed a 3.27 fold increase in the risk of intracranial hemorrhage during pregnancy and puerperium.

Based on the data, we believe there may be a slightly increased risk of hemorrhage during the second and third trimesters and puerperium in patients harboring a brain AVM. However, the increased risk of hemorrhage is still quite low overall, approximately 5%.

The management of a brain AVM can be challenging for the clinician and quite stressful for the patient and her family. There are four accepted management modalities: observation, surgical resection, endovascular treatment, and radiation therapy or a combination thereof (

). However, one of the first management questions that must be answered is whether the AVM has ruptured (

A ruptured brain AVM entails significant morbidity and mortality for mother and fetus.

Patients with previous AVM rupture are at higher risk of re-rupture in subsequent years. Therefore, symptomatic AVMs in pregnant women should be treated as they would be in patients who are not pregnant. The timing here varies, and waiting for up to a month or more is accepted for surgical resection in AVMs that have bled. 

The time allows for the resorption of some intracranial blood products and reduces the edema in the associated brain parenchyma. For endovascular treatment or in the case of a clearly ruptured perinidal aneurysm, treatment may proceed immediately after the inciting event. 

In general, the decision about treatment time varies among centers, and the specific timing and treatment modality of a ruptured cerebral AVM in pregnancy should be made using a multidisciplinary approach to ensure the AVM’s hemodynamic stability and the mother’s safety.

The type of bleeding from an AVM is also important. Most brain AVMs that rupture present with intraparenchymal hemorrhage. If there is only subarachnoid blood, it may be a sign of a ruptured perinidal or intranidal aneurysm, which should be treated and managed accordingly.

Catheter angiogram is the gold standard for characterizing and planning treatment of AVMs and their associated high-risk features. Catheter cerebral angiogram is thought to deliver approximately 0.17 to 2.8 mGy of radiation to the fetus, which is well below the accepted limit of 50 mGy.

However, physicians generally take a “mother first” approach in cases of a ruptured brain AVM during pregnancy. Because of increased mother/fetus morbidity and mortality in these cases, the use of radiation should be weighed against the risk of further hemorrhage and detriment to the mother’s well-being. We therefore recommend performing a catheter angiogram of the ruptured AVM to fully characterize and explore it.

Planning for the treatment of an AVM should be made by a multidisciplinary team on a case-by-case basis. In the paper by Porras et al, 9 pregnant women with ruptured brain AVMs were treated in various ways: radiation, surgery, endovascular means, or a combination thereof.

The treatment of a ruptured AVM is complex and beyond the scope of this paper. However, these patients are likely best managed at centers where all treatment modalities are offered and treating services (eg, neurosurgery, radiation-oncology, and interventional neuroradiology) can discuss how to formulate a plan that best fits the patient.

An unruptured AVM can be discovered in different ways. The patient may present with seizure or focal neurologic deficits, or she may have known about it before becoming pregnant. It may also be discovered incidentally during brain imaging for headaches or other unrelated pathology.

As previously mentioned, diagnosis of a brain AVM can cause significant stress and worry for everyone involved, and its risk of rupture during pregnancy is yet to be determined. Although it probably increases during pregnancy, it is still very small.

Most physicians agree that unruptured AVMs without high-risk features (eg, venous ectasia/stenosis or perinidal aneurysm) should be managed conservatively and that no treatment (surgery, radiation, or endovascular treatment) is warranted in the pregnant patient.

 This is because the risk of treatment is greater than the risk of hemorrhage.

A recent randomized controlled trial, the ARUBA trial, showed that medical management alone is superior to interventional therapy at preventing death or stroke in patients with unruptured brain AVMs who were followed for 33 months (no pregnant patients were included).

 However, the trial has received fierce criticism for considerable selection bias, poor generalizability, questionable clinical practices (only 15.8% of patients underwent surgical resection, the gold-standard treatment), and short follow-up (33 months) in light of the lifelong risk posed by the disease.

 Several extended trials are ongoing to further characterize the best treatment modalities in unruptured brain AVMs.

No clear guidelines exist about the management of the high-risk components (perinidal aneurysm, arteriovenous fistula, and venous outflow restriction) of an AVM during pregnancy. In these situations, a multidisciplinary approach should be taken, and the risks and benefits of treatment weighed on an individual basis.

In our opinion, a conservative treatment approach should be taken in most cases of an incidentally discovered lesion, unless its high-risk features are considered relatively safe to treat.

Many patients with brain AVMs can have an increased risk of seizures, particularly if the AVM involves the temporal lobe. Seizure prevention and management is therefore particularly important in these patients. However, prescribing antiepileptic drugs in pregnancy can be extremely challenging for the clinician. Many of these medications have well-known teratogenic effects, and these effects must be conveyed to the mother.

 We would emphasize the need for referral to a neurologist and a high-risk obstetrician before prescribing or continuing the patient’s antiepileptics.

We do not recommend screening otherwise asymptomatic patients for brain AVMs. Because observation is the most prudent management option of an unruptured AVM, screening pregnant patients leads to increased stress and anxiety for them. 

This recommendation extends even to those with a known diagnosis of hereditary hemorrhagic telangiectasia, an autosomal dominant condition that tends to occur in the lungs, brain, and liver. If brain imaging is required during pregnancy, we recommend first performing a brain MRI, which does not deliver any ionizing radiation to the patient or fetus. If vessel imaging is required, we recommend a brain MRA without contrast, or Time-of-flight MRA, as a first-line modality. 

Gadolinium-based contrast (MRI) is currently contraindicated in pregnant patients. Based on the clinical picture and the opinion of the neurointerventionalist or neuroradiologist, a CTA or cerebral angiogram may be recommended as the next step. Although these exams use ionizing radiation, when performed on areas of the body other than the abdomen and pelvis, they deliver minimal radiation to the fetus.

The absolute risks of fetal effects, including childhood cancer induction, are small at conceptus doses of 100 mGy and negligible at less than 50 mGy.19 It has been reported that fetal exposure after angiography and embolization of a brain AVM is somewhere between 0.17 mGy and 2.8 mGy—far below the safety threshold.

Hemorrhage from a brain AVM during delivery is a major concern of obstetricians and patients alike. Available data would suggest that in most cases vaginal delivery does not carry a higher risk for hemorrhage than Cesarean section.

 However, no data exists as to whether Cesarean section reduces the already low incidence of AVM-associated complications during childbirth. 

Thus, it is up to the clinician and patient to choose the best delivery method; an unruptured brain AVM should be considered but must be weighed against the rest of the clinical context and the patient’s wishes.

Low-dose aspirin has been used during pregnancy, most commonly to prevent or delay the onset of preeclampsia. The Hypertension in Pregnancy Task Force Report from the American College of Obstetricians and Gynecologists recommends daily low-dose aspirin beginning in the late first trimester for women with a history of early-onset preeclampsia and preterm delivery at less than 34 0/7 weeks of gestation and for women with more than one prior pregnancy complicated by preeclampsia.

No clear, evidence-based recommendations or studies exist about the risk of brain AVM rupture in patients taking aspirin. However, based on the known safety of aspirin use in intracranial aneurysms, we would not recommend stopping aspirin or changing the antiplatelet regimen based solely on the presence of a brain AVM.

Although the risk of hemorrhage in pregnant patients with brain AVMs increases slightly during the second and third trimesters and the puerperium, it remains quite low. Therefore, we recommend observation of patients who present with an unruptured AVM. Ruptured brain AVMs in these patients should be treated like those in nonpregnant patients. Pregnant patients with brain AVMs, ruptured and unruptured, are best managed at centers where all complex treatments are offered and where neurosurgery, radiation-oncology, and interventional neuroradiology can together decide how best to develop treatment plans for individual patients.

Dalton A, Dobson G, Prasad M, Mukerji N. 

 intracerebral arteriovenous malformations and a review of the theories of their formation. 

. 2018;32(3):305-311. doi:10.1080/02688697.2018.1478060

Pabaney AH, Rammo RA, Tahir RA, Seyfried D. Development of De Novo arteriovenous malformation following ischemic stroke: case report and review of current literature. 

. 2016;96:608.e5-608.e12. doi:10.1016/j.wneu.2016.09.062

Mohr JP, Kejda-Scharler J, Pile-Spellman J. Diagnosis and treatment of arteriovenous malformations

. 2013;13(2):324. doi:10.1007/s11910-012-0324-1

Maggioni F, Alessi C, Maggino T, Zanchin G. Headache during pregnancy. 

. 1997;17(7):765-769. doi:10.1046/j.1468-2982.1997.1707765.x

Spetzler RF, Martin NA. A proposed grading system for arteriovenous malformations. 

. 1986;65(4):476-483. doi:10.3171/jns.1986.65.4.0476

Brown RD Jr, Wiebers DO, Forbes G, et al. The natural history of unruptured intracranial arteriovenous malformations. 

. 1988;68(3):352-357. doi:10.3171/jns.1988.68.3.0352

van Beijnum J, Lovelock CE, Cordonnier C, et al; SIVMS Steering Committee and the Oxford Vascular Study. Outcome after spontaneous and arteriovenous malformation-related intracerebral haemorrhage: population-based studies.

. 2009;132(2):537-543. doi:10.1093/brain/awn318

Fukuda K, Hamano E, Nakajima N, et al. Pregnancy and delivery management in patients with cerebral arteriovenous malformation: a single-center experience. 

 (Tokyo). 2013;53(8):565-570. doi:10.2176/nmc.53.565

Lv X, Liu P, Li Y. The clinical characteristics and treatment of cerebral AVM in pregnancy. 

. 2015;28(3):234-237. doi:10.1177/1971400915589692

Liu XJ, Wang S, Zhao YL, et al. Risk of cerebral arteriovenous malformation rupture during pregnancy and puerperium. 

. 2014;82(20):1798-1803. doi:10.1212/WNL.0000000000000436

Horton JC, Chambers WA, Lyons SL, Adams RD, Kjellberg RN. Pregnancy and the risk of hemorrhage from cerebral arteriovenous malformations. 

. 1990;27(6):867-872. doi:10.1097/00006123-199012000-00002

Gross BA, Du R. Hemorrhage from arteriovenous malformations during pregnancy. 

. 2012;71(2):349-355. doi:10.1227/NEU.0b013e318256c34b

Lee S, Kim Y, Navi BB, et al. Risk of intracranial hemorrhage associated with pregnancy in women with cerebral arteriovenous malformations. 

. 2021;13(8):707-710. doi:10.1136/neurintsurg-2020-016838

Porras JL, Yang W, Philadelphia E, et al. Hemorrhage risk of brain arteriovenous malformations during pregnancy and puerperium in a North American cohort. 

. 2017;48(6):1507-1513. doi:10.1161/STROKEAHA.117.016828

Mohr JP, Parides MK, Stapf C, et al. Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial. 

. 2014;383(9917):614-621. doi:10.1016/S0140-6736(13)62302-8

Link TW, Winston G, Schwarz JT, et al. Treatment of unruptured brain arteriovenous malformations: a single-center experience of 86 patients and a critique of the A randomized trial of unruptured brain arteriovenous malformations (ARUBA) trial. 

. 2018;120:e1156-e1162. doi:10.1016/j.wneu.2018.09.025

Derdeyn CP, Zipfel GJ, Albuquerque FC, et al. Management of brain arteriovenous malformations: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. 

. 2017;48(8):e200-e224. doi:10.1161/STR.0000000000000134

Gedzelman E, Meador KJ. Antiepileptic drugs in women with epilepsy during pregnancy. 

. 2012;3(2):71-87. doi:10.1177/2042098611433192

McCollough CH, Schueler BA, Atwell TD, et al. Radiation exposure and pregnancy: when should we be concerned? 

. 2007;27(4):909-918. doi:10.1148/rg.274065149

Ogilvy CS, Stieg PE, Awad I, et al. Recommendations for the management of intracranial arteriovenous malformations: a statement for healthcare professionals from a special writing group of the Stroke Council, American Stroke Association. 

. 2001;103(21):2644-2657. doi:10.1161/01.cir.103.21.2644

Dias MS, Sekhar LN. Intracranial hemorrhage from aneurysms and arteriovenous malformations during pregnancy and the puerperium. 

. 1990;27(6):855-866. doi:10.1097/00006123-199012000-00001

Coskun D, Mahli A, Yilmaz Z, Cizmeci P. Anesthetic management of caesarean section of a pregnant woman with cerebral arteriovenous malformation: a case report. 

. 2008;1(1):327. Published 2008 Nov 18. doi:10.1186/1757-1626-1-327

Santos Carvalho C, Resende F, Centeno MJ, Ribeiro I, Moreira J. Anesthetic approach of pregnant woman with cerebral arteriovenous malformation and subarachnoid hemorrhage during pregnancy: case report. 

. 2013;63(2):223-226. doi:10.1016/j.bjane.2012.05.004

Craig JJ, Scott S, Leach JP. Epilepsy and pregnancy: identifying risks. 

. 2022;22(2):98-106. doi:10.1136/practneurol-2019-002304.

Articles

Risk assessment and management of brain arteriovenous malformations in pregnancy.

Demystifying AVMs

Regular health screenings are essential to maintaining overall health and critical for detecting when something is not right with your body. As every obstetrician and gynecologist knows, for women, early cancer detection through annual breast and gynecologic screenings is key for optimal treatment and management.

At times, however, events like the COVID-19 pandemic can intervene and cause patients to miss or skip yearly screenings, thus losing an opportunity to detect an abnormality early. In fact, a recent survey published in 

 found that between 2018 and 2020, breast and cervical cancer screenings decreased by 6% and 11%, respectively.¹ The authors discovered that “early in the pandemic when routine procedures were paused, [breast cancer] screening volumes decreased more sharply among Hispanic, Asian, and American Indian and Alaska Native[s].”

According to Ahmedin Jemal, DVM, PhD, senior study author, and senior vice president of the American Cancer Society, the “COVID-19 pandemic had an immediate impact in March and April of 2020, as screenings initially dropped by close to 80%,” and although “many people caught up on screenings later in 2020 . . . overall, the . . . pandemic kept screenings down over the course of the entire year. As we move forward, it’s crucial to get people back into their doctor’s offices to get screened.”

Aside from delayed detection, misdiagnosis can also alter treatment. In this month's issue, you’ll find our 

 column, written by Jim M. Shwayder, MD, JD; and Hindi Stohl, MD, JD, which discusses how clinicians can prevent, and navigate, a breast cancer misdiagnosis.

Remember that, as Jemal pointed out, it is imperative for you and your
patients that annual screenings be conducted on time to that ensure irregularities are caught as early as possible. 

1. Fedewa SA, Star J, Bandi P, et al. Changes in cancer screening in the US during the COVID-19 pandemic. 

. 2022;5(6):e2215490. doi:10.1001/jamanetworkopen.2022.15490

It is imperative for you and your patients that annual screenings be conducted on time to that ensure irregularities are caught as early as possible.

A missed opportunity: annual screenings are essential

As we were going to press, the United States Supreme Court overturned Roe v Wade, eliminating the constitutional right to an abortion, and leaving the question of abortion rights to the states.

Jared Robins, MD, is executive director of the American Society for Reproductive Medicine (ASRM). Prior to joining ASRM, he was a practicing reproductive endocrinologist working in both academic and private settings.

Sean Tipton serves as the chief policy and advocacy officer for the American Society for Reproductive Medicine. He has more than 20 years experience working on reproductive health issues.

As we head into summer, all eyes will be turning to the Supreme Court in anticipation of its decision in the case of 

, which is challenging a Mississippi law that bans abortions after 15 weeks of gestation. The court heard arguments in the case in December 2021. 

Based on questions posed at the time and on previous decisions by the majority of the justices, most observers expect the Mississippi law will be upheld, effectively overturning 

 and ending the constitutional right to pregnancy termination in the United States. This expectation is further supported by the recent and unprecedented leak of Justice Samuel Alito’s draft decision, which challenges the validity of


The implications for abortion care of overturning 

 are clear. Each state will be free to restrict or ban abortions as it sees fit. Indeed, many have already passed laws that do this, and 13 have “trigger laws” ready to go into effect as soon as 

 is undone. A variety of approaches are being taken. Like Mississippi, many states are developing time-based restrictions (eg, abortion bans after a given gestation time). Others, anticipating a complete reversal of 

However, restrictions will not be limited to pregnancy termination. If the rationale Justice Alito described in the leaked decision is accepted, the whole framework that has given rise to reproductive and sexual privacy may be at risk. The leaked decision very much sets the stage for challenges to the decisions that protected same-sex marriage, struck down antisodomy statutes, and established the right to contraception.

Fertility care is also at significant risk. Many of the bills being introduced in statehouses around the country (over 500 have already been put forward, according to the Guttmacher Institute) include language defining a fertilized egg as a legal human entity.

 The terminology varies, which makes it difficult to generalize, but the danger is clear. 

If the legal status of fertilized eggs or early embryos is codified, in vitro fertilization (IVF) procedures may become legally risky for patients, physicians, and staff. 

The danger posed by some legislative proposals is obvious. For instance, Nebraska’s Legislative Bill 933 (the state has a unicameral legislature) asserts that an “unborn child means an individual living member of the species homo sapiens, throughout the embryonic and fetal stages of development from fertilization to full gestation and childbirth” and that the “causing or abetting the termination of life of an unborn child” will be unlawful. This bill clearly classifies an IVF-created embryo as an unborn child.

If you put a 3-year-old child in a freezer, you will kill them and presumably will have committed homicide. But what if you put a blastocyst in a cryopreservation tank? Most blastocysts will survive the thaw. However, the risk of not surviving is approximately 1%. Would that constitute homicide? 

This happens every day in fertility clinics. In fact, most children born as a result of IVF procedures in the United States are born from frozen embryos. According to the Society for Assisted Reproduction (SART), 85.5% (n = 62,915) of total live births from embryo transfers in 2020 (N = 73,602) were transfers of thawed embryos.

Sometimes these questions are even more challenging. Oklahoma’s SB 1553 also defines life and legal status as beginning at fertilization—but also bans acts that would “induce an abortion if more than 30 days have elapsed since the probable beginning of the last menstrual cycle of the pregnant woman.” 

Obviously, the “probable last menstrual cycle” from which a frozen embryo is derived may have taken place a long time before the embryo is used. How, then, does this wording apply to in vitro procedures? Your guess is as good as ours. 

But it’s safe to say that none of the physicians providing infertility services want to be the test case that determines whether they have violated the law by putting a “person” in a tank of liquid nitrogen.

The ability to cryopreserve sperm, eggs, and embryos has revolutionized infertility care over the past 20 years. Contemporary best practices in IVF call for a single embryo transfer to mitigate the risk of multiple births. Some clinics perform “freeze all” cycles, whereas others transfer 1 embryo immediately and freeze the rest for subsequent use. Under some proposed legislation, the legal status of these embryos could be in flux. The use of single frozen embryos has enabled fertility doctors to improve the safety of procedures without compromising the probability of pregnancy from one in vitro fertilization cycle. In fact, SART reports that 88.3% of all live births (fresh and frozen embryo transfers) were singletons, and 89.5% of live births from frozen embryos were singletons.

In addition, the use of preimplantation genetic diagnosis has allowed physicians to determine whether embryos carry genetic diseases, such as Huntington and Tay-Sachs disease, and thus to eliminate these horrible conditions from the blood lines of patients. However, this technique requires the use of frozen embryos. What becomes of embryos that are not transferred because they are known to carry such diseases? Will they remain frozen forever, and who will pay for this?

The legislative risk to IVF is not limited to frozen embryos. Problems in an IVF lab can impact embryo health. In fact, only about 60% of fertilized eggs survive to the blastocyst stage in the lab. 

 At what point will the embryos be considered nonviable? Can a physician be accused of impacting viability? What happens if equipment failure affects the culture of a blastocyst? What if the embryologist accidentally drops an embryo? Although these events are very rare, do they constitute homicide? What if a tank of frozen embryos fails and the embryos are destroyed: Would that be considered mass murder? Will physicians still be allowed to offer patients the best treatments, or will they risk being charged with a felony? For America’s fertility doctors, these are no longer hypothetical questions.

The moral and legal status of the developing fetus is a complicated question, one that science is poorly equipped to answer. Unfortunately, the current political and legal environment in the United States does not lend itself to informed, complicated, or nuanced discussions. 

As a result, we will be dealing with blunt policy outcomes. “Life begins at conception” has become an article of faith for some in the antichoice community. For others, however, reality can intrude. Thus, we get laws that allow abortion in cases of rape or incest. Only the most extreme elements of the antichoice movement would want to consign women with ectopic pregnancies to death and, therefore, most legislative proposals allow them to be treated. 

Nevertheless, we have seen states seeking to ban such treatments or mandate what we know is scientifically unsound to “save” ectopic pregnancies. Similarly, some state laws attempt to carve out contraception, although these attempts may be more about bowing to political realities than about the appreciation of scientific facts.

IVF is one risk facing reproductive care if 

 is overturned. But it’s far from the only risk. 

, rest in part on a crucial right not explicitly articulated in the first 10 amendments to the Constitution: the right to privacy. 

This right was fundamental to the findings in 

, which established the right to contraception originally available only to married women. Should the Supreme Court overturn Roe, that decision might include an explicit rejection of the right to privacy, which could have crucial implications for reproductive medicine.

We have already seen laws enacted that make treating transsexual patients illegal, in most cases based on age, but now we are seeing bills that block the care of adult patients as well. 

If there is no constitutional right to privacy, there may be no end to the government’s right to limit reproductive medical procedures. If abortion and caring for trans patients can be made illegal, why should we suppose there will be a meaningful limit to what state legislatures or Congress could ban?

Most antichoice activists, and the politicians doing their bidding, don’t really want to stop would-be parents from receiving the medical treatments they need to raise families. However, they seem to have no problem if the infertile are the collateral damage required to win the abortion wars. 

Let us know what you think current political climate around abortion and how it is affecting your practice and the ability to care for your patients. Email cspong@mjhlifesciences.com.

1. Nash E, Cross L, Dreweke J. 2022 State legislative sessions: abortion bans and restrictions on abortion dominate. Guttmacher Institute. March 16, 2022. Accessed May 4, 2022. https://www.guttmacher.org/article/2022/03/2022-state-legislative-sessions-abortion-bans-and-restrictions-medication-abortion

2. Preliminary national summary report for 2020. Society for Assisted Reproductive Technology. Accessed May 4, 2022. https://www.sartcorsonline.com/rptCSR_PublicMultYear.aspx?reportingYear=2020

As we were going to press with the July issue, the United States Supreme Court overturned Roe v Wade, eliminating the constitutional right to an abortion, and leaving the question of abortion rights to the states.

Not just abortion: How the demise of Roe v Wade may impact fertility care

Natasha Schimmoeller, MD, MPH, MA, is an assistant professor in the Division of Family Planning within the Department of Obstetrics and Gynecology at Cedars-Sinai Medical Center in Los Angeles, California.

Bryna J. Harwood, MD, is director of Gynecologic Specialties and the Obstetrics and Gynecology Residency Program at Cedars-Sinai Medical Center in Los Angeles, California.

Editor’s Note: This month’s editorial was written by a guest editor.

Abortion restrictions affect all of us. One in 4 women in the United States choose to end a pregnancy by age 45.

 Statistically speaking, everyone knows someone who has had an abortion.

 These women are not only our patients, but our mothers, sisters, friends, colleagues— even ourselves. As a family planning subspecialist, I see my future self in nearly every one of my patients. 

Whether I’m rushing to the hospital in the middle of the night to perform a life-saving dilation and evacuation for a woman in septic shock or providing a routine medication abortion to a patient with contraceptive failure, I think about the women in states like Texas who are experiencing the same complications but lack access to basic, evidence-based reproductive care. I think about the families who have already lost or will lose loved ones because of the legislative restriction of abortion. I think about the physicians, trainees, nurses, and staff who are forced to act against the ethical tenets of the medical profession and deny the human responsibility to be compassionate but instead must watch patients die or suffer life-altering morbidity.

We must face reality. For decades, the doctor-patient relationship and the basic human right of reproductive autonomy have been subjected to a methodical attack. We know what will happen if the Supreme Court overturns long-standing legal precedent and gives states unchecked power to restrict abortion. Twenty-six states are certain or likely to ban abortion altogether.

 Excluding unsafe abortion, forced pregnancy alone will lead over time to an estimated 21% increase in maternal mortality, with a 33% increase for Black women.

 The Turnaway Study demonstrated the harm inflicted on women and all their children when they are denied abortions, including years of economic hardship and insecurity.

 The women in my life—patients, friends, family, coworkers—are telling me they are scared, and their apprehension is justified.

As physicians, we have power. Here are some things you can do:

If you are in a permissive state, integrate abortion into your practice. Eighty percent of abortions occur at or below 10 weeks’ gestation. Just providing medication abortion is helpful.

If you are in a restricted state, have a referral plan.

Use resources like ACOG’s Spontaneous and Induced Abortion Resource Center, which can answer clinical questions and help with reimbursement and with starting new services.

Teach trainees and preserve our workforce.

Make time to vote and remind patients to do the same.

Streamline care in your institution, connect with other doctors, or just say the word 

1. Induced abortion in the United States. Guttmacher Institute. September 2019. Accessed June 2, 2022. https://www.guttmacher.org/fact-sheet/induced-abortion-united-states

2. National Network of Abortion Funds. Accessed June 2, 2022. https://abortionfunds.org/

3. Nash E, Cross L, Dreweke J. Roe v. Wade in peril: our latest resources. Guttmacher Institute. 2022. Accessed June 2, 2022. https://www.guttmacher.org/abortion-rights-supreme-court

4. Stevenson AJ. The pregnancy-related mortality impact of a total abortion ban in the United States: a research note on increased deaths due to remaining pregnant. 

. 2021;58(6): 2019-2028. doi:10.1215/00703370-9585908

5. Foster DG, Biggs MA, Ralph L, Gerdts C, Roberts S, Glymour MM. Socioeconomic outcomes of women who receive and women who are denied wanted abortions in the United States. 

. 2018;108(3):407-413. doi:10.2105/AJPH.2017.304247

6. Miller S, Wherry LR, Foster DG. The economic consequences of being denied an abortion. The National Bureau of Economic Research Working Paper No. 26662. January 2020. Accessed June 2, 2022. doi:10.3386/w26662

7. Foster DG, Raifman SE, Gipson JD, Rocca CH, Biggs MA. Effects of carrying an unwanted pregnancy to term on women’s existing children. 

. 2019;205:183-189.e1. doi:10.1016/j.jpeds.2018.09.026

8. Foster DG, Biggs MA, Raifman S, Gipson J, Kimport K, Rocca CH. Comparison of health, development, maternal bonding, and poverty among children born after denial of abortion vs after pregnancies subsequent to an abortion. 

. 2018;172(11):1053-1060. doi:10.1001/jamapediatrics.2018.1785

9. Implementing progress in abortion care and training (IMPACT). ACOG. Accessed June 2, 2022. 

10. About us. Vot-ER. March 28, 2022. Accessed June 2, 2022. 

How you can help patients during the current attack on their reproductive autonomy

Having an impact: How you can help your patients in the wake of Roe v Wade overruling

These infections can cause symptoms like burning, itching, or even pain during and after intercourse. When these infections become chronic or recurrent, the women who experience them usually have to rely on symptomatic control rather than trying to actually resolve the fungal infection.

, sought to develop a consensus among vulvovaginal experts on the best ways to treat chronic or recurrent yeast infections.

For episodic yeast infections, over-the-counter antifungal treatments or a single oral dose of fluconazole are usually used and can resolve symptoms to produce a negative culture in up to 90% of women who complete the regimen.

Recurrent yeast infections, however, are rarely ever “cured.” Curing the fungal infection completely is nearly impossible, and most women with this condition aim instead for mycologic control. This usually takes more than a single course of oral fluconazole—normally 3 doses—or up to 2 weeks of topical treatment. Beyond this initial treatment strategy, however, there is little guidance on what it takes to maintain that control.

The Centers for Disease Control and Prevention (CDC) recommends the use of oral fluconazole weekly for 6 months as an initial first-line treatment for recurrent yeast infections. If oral antifungal medication can’t be used for a number of reasons, the CDC suggests that intermittent topical treatments can be used, but the type and frequency of these treatments isn’t specified.

The study authors note that while most women prefer oral fluconazole over topical medications for convenience, its use may carry additional risk for women:

Additionally, the study reveals that fluconazole may not be effective against infections caused by the nonalbicans species of fungi, which is responsible for up to 20% of recurrent yeast infections. There are some other options for oral treatment, too, including ibrexafungerp. This medication was approved by the U.S. Food and Drug Administration in June 2021 and is taken in just 2 doses given the same day. It kills the fungus instead of just stopping its growth like fluconazole, but is also contraindicated during pregnancy.

Other management strategies for mycologic control in recurrent yeast infections may include things like:

Vulvovaginal candidiasis (VVC)—commonly known as a yeast infection—is a problem many women face at some point. About half of all women have had at least 1 of these infections clinical diagnosed, and between 6% and 10% are believed to develop a recurrent form of this condition with 3 to 4 or more episodes in a single year, according to a new report.

Vol 67 No 7

Demystifying AVMs

A missed opportunity: annual screenings are essential

Not just abortion: How the demise of Roe v Wade may impact fertility care

Having an impact: How you can help your patients in the wake of Roe v Wade overruling

Twice weekly maintenance therapy ideal for recurrent yeast infections

Vulvodynia not associated with vulvovaginal candidiasis