Pregnancy and Stroke

Dr Kneale MetcalfConsultant Stroke Physician NNUHFT

Overview

• Incidence• Risk factors• Management• Outcome• Avoid

Incidence

• Varies according to study• Depends on whether you include post-partum

events• Some studies pre date imaging

• Estimates 4-11 / 100,000 deliveries

Incidence

Results (antenatal)

• 1.5 cases per 100,000• 0.9 infarcts• 0.6 haemorrhagic

• Note event cluster around time of birth

Maternal changes

• Haemostasis– Overall balance = pro-coagulant– Especially 3rd trimester – Return to normal 3 weeks after delivery

• Haemodynamic– Increased cardiac output – Initial reduced BP, then increases to delivery

Risk factors

• Hypertension• Diabetes• Heart disease• Sickle cell• Thrombolphilia

Risk factors

• Alcohol• Smoking• Substance abuse• Age (>35y)• Migraine

Risk factors (UK study)

• Hx migraine (OR 8.5)• Hx gestational DM (OR 26.8)• Hx pre or eclampsia (OR 7.7)

• Risk stroke – every mmHg highest recorded during pregnancy– Systolic = 3%– Diastolic = 8%

Pregnancy specific risks

• Caeserean• Pre / Eclampsia– Hypertension– Proteinuria– Oedema– Then ….headache, confusion, seizures

• Amniotic fluid embolism• Post partum cerebral angiopathy• Peripartum Cardiomyopathy

Presentation

• Standard but….– Presented with reduced consciousness or collapse• 30% ischaemic• 37% haemorrhagic

– Presented with seizure in 33% haemorrhagic strokes

Sub classification of antenatal strokes

Imaging considerations

• CT – Radiation– Definitely avoid in first few weeks

• CT perfusion– Radiation dose

• MRI– Noise– Vibration– Magnetic field– Avoid Gadalinium

Treatment

• Haemorrhage – standard• Venous Sinus Thrombosis – standard

• Remember risks versus benefit, including the foetus

• Infarct – controversial. 11 case reports using Alteplase

• Legal situation??

Real world

• Remember your differential…..– Migraine – Eclampsia

• Remember venous sinus thrombosis– If very bad ?intervention

• Get the best imaging you can safely (MRI)• Get the Obstetricians down ASAP• Communicate ++++++• Consider the baby all the time• Each case will have to be judged on merit• Legal……is doing nothing safe??

Prevention

• Little guidance• Consider – Pregnant past Hx stroke– thrombophilia – Cardiac abnormaities

• Antiplatelet• LMWH

Stroke, 2013;44:864-868

Summary of discussion

• Essentially an evidence free zone• Alteplase not licenced in pregnancy• All respondents were from advanced stroke

centres– Possibility of endovascular intervention

• Alteplase doesn’t cross placental barrier• Disabling stroke is a disaster• More info the better (imaging etc.)• Time is brain

All agreed

• IV thrombolysis possibly with thrombectomy

• But…– They had full MRI imaging and vascular imaging– On site warmed up vascular lab

• Long way from the EoE – but what of the future??

Summary

• May we never have a case!

• Be as sure as you can be it’s a stroke

• Don’t be too petrified to treat

References

Any questions?