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Pregnancy and Stroke

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Pregnancy and Stroke. Dr Kneale Metcalf Consultant 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

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Pregnancy and Stroke

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  1. Pregnancy and Stroke Dr Kneale Metcalf Consultant Stroke Physician NNUHFT

  2. Overview • Incidence • Risk factors • Management • Outcome • Avoid

  3. Incidence • Varies according to study • Depends on whether you include post-partum events • Some studies pre date imaging • Estimates 4-11 / 100,000 deliveries

  4. Incidence

  5. Results (antenatal) • 1.5 cases per 100,000 • 0.9 infarcts • 0.6 haemorrhagic • Note event cluster around time of birth

  6. 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

  7. Risk factors • Hypertension • Diabetes • Heart disease • Sickle cell • Thrombolphilia

  8. Risk factors • Alcohol • Smoking • Substance abuse • Age (>35y) • Migraine

  9. 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%

  10. Pregnancy specific risks • Caeserean • Pre / Eclampsia • Hypertension • Proteinuria • Oedema • Then ….headache, confusion, seizures • Amniotic fluid embolism • Post partum cerebral angiopathy • Peripartum Cardiomyopathy

  11. Presentation • Standard but…. • Presented with reduced consciousness or collapse • 30% ischaemic • 37% haemorrhagic • Presented with seizure in 33% haemorrhagic strokes

  12. Sub classification of antenatal strokes

  13. Imaging considerations • CT • Radiation • Definitely avoid in first few weeks • CT perfusion • Radiation dose • MRI • Noise • Vibration • Magnetic field • Avoid Gadalinium

  14. Treatment • Haemorrhage – standard • Venous Sinus Thrombosis – standard • Remember risks versus benefit, including the foetus • Infarct – controversial. 11 case reports using Alteplase • Legal situation??

  15. 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??

  16. Prevention • Little guidance • Consider • Pregnant past Hx stroke • thrombophilia • Cardiac abnormaities • Antiplatelet • LMWH

  17. Stroke, 2013;44:864-868

  18. 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

  19. 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??

  20. 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

  21. References

  22. Any questions?

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