“This notice provides important information regarding your drinking water. We are providing this information because our water system exceeded the

PFAS (per- and polyfluoroalkyl substances)

drinking water standard….This is not an emergency….Consumers in a sensitive group (pregnant or nursing women, infants, immunocompromised) are advised not to consume, drink, or cook with [the town] water…and consult with their physician.”

—Excerpt from a letter written by local municipality to a pregnant patient

“PF-What?” Despite the declaration that this situation was not an emergency, the letter understandably invoked significant anxiety for our patient. When an environmental health risk such as this arises, patients often seek guidance from their clinicians. However, many practicing obstetrician-gynecologists have limited knowledge of and minimal formal education on per- and polyfluoroalkyl substances (PFAS), leaving them ill-equipped to counsel their patients.

PFAS are synthetic chemicals with a strong carbon-fluorine bond, which allows PFAS to resist heat and repel both water and fat (eg, grease or oil). Their remarkable, stain-resistant properties have led to their widespread use in a variety of consumer products for more than 7 decades.

 PFAS are used in nonstick cookware, water- or stain-repellant carpet or fabrics, waterproof clothing, fast-food packaging and wrappers, microwave popcorn bags, pizza boxes, shampoos, nail polish, dental floss, firefighting foam, and more 

PFAS are quite resistant to degradation and can persist in the environment for years. They contaminate water, air, and soil via manufacturing facilities’ waste, firefighting foam runoff, and leaching from consumer products in landfills.

 The main pathway of exposure for humans is ingestion of contaminated water or food. Once humans are exposed, most PFAS are not extensively metabolized by the body and are excreted slowly through the urine. Some of the older PFAS have biological half-lives of years or even decades. Consequently, PFAS are considered to be “forever chemicals” in both the environment and human bodies.

Given the persistence of PFAS in the environment and the common pathways of exposure, almost everyone has measurable levels of PFAS in their blood.

 Firefighters and individuals who work in occupational settings that manufacture PFAS may be exposed to higher levels than the general population. Infants may be exposed to transplacental exposure during pregnancy or from breast milk. In the United States, serum PFAS concentrations have been declining over the past 2 decades following the voluntary phaseout of 2 long-chain PFAS, perfluorooctanoic acid (PFOA) and perfluorooctanesulfonic acid (PFOS), by US manufacturers.3 Although this downward trend is encouraging, there is growing concern about the widespread industrial use of short-chain PFAS as alternatives to long-chain PFAS because their health risks are not as well known.

What are potential health concerns from PFAS exposure? What are the risks during pregnancy?

A variety of health outcomes have been raised as potentially resulting from exposure to PFAS 

Possible health effects include an increased rate of obesity, elevated cholesterol levels, abnormal liver tests, thyroid dysfunction, increases in testicular and kidney cancers, ulcerative colitis, learning difficulties, attention-deficit/hyperactivity disorder, delayed puberty, and reduced immunologic responses to vaccines. PFAS exposure has been reported to increase the risk of infertility, miscarriage, low birth weight, and preeclampsia. It is important to emphasize that the scientific community’s understanding of how PFAS affects human health is evolving and that no single study can establish causality. 

There are limitations in extrapolating effects observed in animal experiments to humans and teasing out potential confounding and coexposures from human cohorts. Nonetheless, the array of potential health outcomes associated with PFAS is worrisome given their persistence in the environment and human bodies.

Some of the most robust evidence regarding the negative health outcomes associated with PFAS exposure is from the C8 Science Panel, which was established as part of a legal settlement between residents of the Ohio River Valley in West Virginia and Ohio and a manufacturer of PFOA that contaminated the air and residents’ local drinking water with millions of pounds of its facility’s waste. PFOA also is known as C8 because of its 8 carbon atoms. 

The panel undertook a number of complementary studies from 2005 to 2013 with participation from more than 69,000 adults, including several studies that analyzed birth outcomes.6 The panel concluded that there was a probable link between PFOA exposure and 6 specific health outcomes: increased serum cholesterol levels, ulcerative colitis, thyroid disease, testicular cancer, kidney cancer, and pregnancy-induced hypertension and preeclampsia (hypertensive disorders of pregnancy).

The C8 panel reviewed results from 4 preeclampsia studies. Even though the studies differed in how and when they measured PFAS exposure during the pregnancy, the panel concluded there was a probable link between PFAS exposure and preeclampsia. In the largest study, results from more than 10,000 individuals found that preeclampsia was 40% more likely in those with measured PFOA levels in the highest quintile of exposure compared with those in the lowest 2 quintiles.

 It is important to emphasize these studies were conducted among a highly exposed population. 

Nonetheless, a recent study conducted among a population with exposures more typical of the general population demonstrated an increased odds for late-onset preeclampsia for those exposed to 2 of the longer-chain PFAS, PFOA, and PFOS.

Among the reproductive health outcomes analyzed—preeclampsia, miscarriage, birth defects, stillbirths, preterm birth, and low birth weight—the C8 panel was only able to confirm an association between PFOA and preeclampsia. That said, research devoted to PFAS exposure in human cohorts, beyond animal toxicology studies, is rapidly increasing. To stay up-to-date, clinicians can access the PFAS-Tox Database online, a “living systematic evidence map” updated frequently with new human, animal, and laboratory studies and organized by health systems. 

It will take time to better understand whether other reproductive health outcomes are associated with PFAS exposure, at what levels risk occurs, and whether risks are associated with the shorter-chain PFAS being proposed as alternatives to the older PFOA and PFOS. Although touted as safer alternatives to longer-chain PFAS, emerging evidence suggests shorter-chain PFAS may still be able to disrupt reproductive and endocrine functions.

How should I counsel my patients about reducing PFAS exposure?

There are ways individuals can reduce exposure to PFAS 

Old, chipped, or damaged nonstick cookware and bakeware should be discarded and replaced with a safer alternative such as stainless steel or cast iron versions, which do not contain PFAS. If nonstick cookware is used, it is important to keep in mind that PFAS within the nonstick coating can break down at high temperatures and off-gas into the air. 

Therefore, patients should cook at low to medium heat and handwash their cookware and bakeware to avoid the high temperatures achieved in the dishwater. Good ventilation also can help to remove any PFAS off-gassing during cooking.

Fast food is often contained in packaging coated with PFAS, including pizza boxes, french fry holders, microwave popcorn bags, and takeout sandwich wrappers. To reduce exposure, patients can limit their fast-food intake or use their own stainless steel or glass containers as substitute takeout containers. Patients can cook popcorn kernels on the stovetop instead of in the microwave. Installing a home water filtration system that is certified to remove PFAS from drinking water is another way to reduce exposure from ingestion. Skin absorbs minimal amounts of PFAS, so no changes to bathing or showering are needed.

Older, frayed carpeting or upholstery should be replaced, particularly in households where children are present as they spend more time on the floor and are more likely to ingest PFAS given their hand-mouth curiosity. Frequent vacuuming and dusting with wet cloths may further decrease PFAS concentrations in the home.

In a study of 37 adults from North Carolina, certain behaviors were associated with changes to measured serum PFAS levels.

 Individuals with more frequent intake of microwaved food had higher PFHxS concentrations while those who vacuumed more often had lower PFHxS concentrations. 

Use of a water filtration device led to lower PFOA concentrations, but higher levels of PFHxS. Although the study was small and some of the results were inconsistent, the results suggest that individual behaviors may have an important role in attenuating the risk of exposure to PFAS.

What if my patient is told the drinking water in their town is above health advisory levels?

In 2016, the Environmental Protection Agency established a health advisory level for PFOA and PFOS in drinking water at 70 parts per trillion (ppt) for either PFAS chemical or combined.

 Some states have even stricter guidelines. 

For example, in Massachusetts, the drinking water standard is
20 ppt for 6 PFAS chemicals, individually or combined. What is confusing to consumers is that these cutoffs were specified with a margin of protection assuming a lifetime of exposure and therefore do not distinguish between safe versus unsafe drinking water. This is not a “Cinderella moment” where at midnight (70 ppt) water should be considered unsafe, whereas at 11:59 pm (69 ppt) it is safe. That said, there is ongoing debate among scientists, regulators, and environmental advocacy groups about whether these levels provide adequate health protection, especially because they specify only a handful of PFAS chemicals. Chronic exposure, even below levels experienced at contaminated sites or specified by these thresholds, may negatively affect health.

For a pregnant or breastfeeding patient living in an area where the drinking water is found to be above the advisory threshold, it is recommended they use alternatives to the tap water until the water levels are brought back into an acceptable range. Bottled water should be used for drinking, cooking, and brushing teeth—but consumers should be aware that not all bottled water is tested for PFAS. 

The United States Food and Drug Administration does not require that bottled water be tested for PFAS. Professional associations, such as the International Bottled Water Association, require members to test annually and maintain levels of less than 10 ppt for 2 or more PFAS, much lower than municipal drinking water standards. 

Some states maintain a list of bottled waters that meet the state drinking water standards. Unfortunately, boiling water does not remove PFAS. Water filters can help but need to be specifically designed to remove PFAS. The benefits of breastfeeding outweigh the risks from PFAS exposure. Breast milk concentrations of PFAS chemicals are typically 10% or less of the adult serum concentrations, varying by the specific chemical.

It is better to switch to alternate drinking sources than to discontinue breastfeeding. If infant nutrition is provided through bottle feeding, alternate water sources should be utilized. Those who are not considered vulnerable (nonpregnant adults) need not alter their drinking water sources.

For patients who receive a notice from their municipality about PFAS, no changes to obstetric clinical care need to be made provided that adequate screening for preeclampsia is occurring at the time of routine prenatal visits. As the ongoing COVID-19 pandemic has interrupted some in-person prenatal care, home blood pressure cuffs should be provided if routine prenatal visits cannot be done in person. Warning signs of preeclampsia should be reviewed.

There is no medication or treatment to administer for PFAS exposure, even if drinking water is above established standards. This is different from acute heavy metal poisoning (eg, acute mercury or lead poisoning), which may require hospitalization and chelation.

Results from testing for levels of PFAS in the blood are not helpful in counseling patients or changing management. Almost everyone in the United States has measurable amounts of PFAS in their blood but the levels do not predict adverse health outcomes, including pregnancy complications such as preeclampsia. Blood levels should be measured only as a part of
research studies.

What other resources are available to learn more about PFAS?

The Agency for Toxic Substances and Disease Registry has published online guidance for health professionals interested in learning more about PFAS.

 Several patient-facing fact sheets are available online and can be printed for sharing with patients.

Providers also can reach out to their regional Pediatric Environmental Health Specialty Units network to pose a specific environmental health clinical question or ask for additional resources. The units function similar to a poison control center for environmental health concerns, and each maintains a reproductive health specialist in addition to pediatric environmental health experts. 

Disclaimer: Wylie has served on the board of the Society for Maternal-Fetal Medicine and is an obstetrics collaborator to the Region 1 Pediatric Environmental Health Specialty Units network. This manuscript was supported by the American Academy of Pediatrics and funded in part by a cooperative agreement with the Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry (CDC/ATSDR). The Environmental Protection Agency (EPA) supports the Pediatric Environmental Health Specialty Units by providing partial funding to CDC/ATSDR through an interagency agreement. The findings and conclusions presented have not been formally disseminated by CDC/ATSDR or EPA and should not be construed to represent any agency determination or policy. Use of trade names that may be mentioned is for identification only and does not imply endorsement by the CDC/ATSDR or EPA.

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Sunderland EM, Hu XC, Dassuncao C, Tokranov AK, Wagner CC, Allen JG. A review of the pathways of human exposure to poly- and perfluoroalkyl substances (PFASs) and present understanding of health effects. 

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Bălan SA, Mathrani VC, Guo DF, Algazi AM. Regulating PFAS as a chemical class under the California Safer Consumer Products Program. 

An overview of the science and guidance for clinicians on per- and polyfluoroalkyl substances (PFAS). Agency for Toxic Substances and Disease Registry. Updated December 6, 2019. Accessed January 17, 2022. https://www.atsdr.cdc.gov/pfas/docs/clinical-guidance-12-20-2019.pdf

Frisbee SJ, Brooks AP Jr, Maher A, et al. The C8 health project: design, methods, and participants. 

C8 probable link reports. C8 Science Panel. Updated October 29, 2012. Accessed January 17, 2022. 

http://www.c8sciencepanel.org/prob_link.html

Savitz DA, Stein CR, Bartell SM, et al. Perfluorooctanoic acid exposure and pregnancy outcome in a highly exposed community. 

 2012;23(2):386-392. doi:10.1097/EDE.0b013e31824cb93

Bommarito PA, Ferguson KK, Meeker JD, McElrath TF, Cantonwine DE. Maternal levels of perfluoroalkyl substances (PFAS) during early pregnancy in relation to preeclampsia subtypes and biomarkers of preeclampsia risk. 

 2021;129(10):107004. doi:10.1289/EHP9091

Rickard BP, Rizvi I, Fenton SE. Per- and poly-fluoroalkyl substances (PFAS) and female reproductive outcomes: PFAS elimination, endocrine-mediated effects, and disease. 

2022;465:153031. doi:10.1016/j.tox.2021/153031

Siebenaler R, Cameron R, Butt CM, Hoffman K, Higgins CP, Stapleton HM. Serum perfluoroalkyl acids (PFAAs) and associations with behavioral attributes. 

 2017;184:687-693. doi:10.1016/j.chemosphere.2017.06.023

Drinking water health advisories for PFOA and PFOS. EPA. Accessed January 17, 2022. 

https://www.epa.gov/ground-water-and-drinking-water/drinking-water-health-advisories-pfoa-and-pfos

Kärrman A, Ericson I, van Bavel B, et al. Exposure of perfluorinated chemicals through lactation: levels of matched human milk and serum and a temporal trend, 1996-2004, in Sweden. 

How PFAS chemicals affect women, pregnancy, and human development. Health and Environmental Alliance. May 20, 2021. Accessed January 17, 2022. 

https://www.env-health.org/wp-content/uploads/2021/05/FIGO-PFAS-Fact-Sheet-FINAL-5.20.2021.pdf

PFAS & health: protecting yourself, your family, and your community from exposure to perfluoroalkyl and polyfluoroalkyl substances. Region 1 New England PEHSU. Accessed January 17, 2022. https://www.childrenshospital.org/sites/default/files/2022-04/pfas-health-factsheet-2022.pdf

Articles

Counsel pregnant and breastfeeding patients about dangers from exposure to PFAS.

Beware of “forever chemicals”

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.

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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.

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 

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.

Vol 67 No 7

Beware of “forever chemicals”

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