STROKE & PREGNANCY By Judith Barnaby, Stroke CNS Reviewed by Dr. Bayer, Stroke Neurologist, St. Michael’s Hospital

Learning Objectives To identify pertinent research statistics that pertain to the subject matter To review physiological changes associated with pregnancy To recognize the risk factors for pregnancy as it relates to stroke To discuss the management therapies To review a case study (stroke and pregnancy): Case analysis and application of theory To review cerebral venous sinus thrombosis

Statistics Stroke is the second leading cause of death of women in Canada and the United States According to Jaigobin & Silver, there is a higher incidence of stroke in young women than in men between the ages of 15 and 30 to 35 years. (Stroke related pregnancy) Pregnancy-related stroke is, a rare, but potentially a devastating event Washington study: 0.7% risk of cerebral infarction during pregnancy and 8.75 during the post-partum period. 2.5% risk of intracerebral bleed during pregnancy and 28.3% post-partum

Statistics Cont’d: Pregnancy related stroke in the UK: 11 to 26 deliveries per Approx. 8% to 15% of pregnancy related stroke victims die C-Section deliveries (3 to 12 times higher risk) than vaginal deliveries A study in the UK identified that thromboembolism was the leading cause of maternal death (a study in the US: 5,723 cases out of 8,918 cases were venous thrombosis in nature) Most common cause of cerebral infarction: eclampsia and preeclampsia. Most common cause of intracerebral bleed: arterial aneurysm and Arteriovenous malformation (AVM)

Physiological Changes Associated with Pregnancy Hypercoagulable state is characteristic of pregnancy 1. Marked increase in fibrinogen and factor VIII (8). Factors VII (7), IX, X and XII are also increased but to a lesser extend. Fibrinolytic activity is depressed during pregnancy and labour 2. Deep Vein Thrombosis (DVT) is a common complication (1 to 2%; vaginal delivery and 2 to 10% for C-section delivery). Pulmonary embolism is a potential complication

Risk Factors for Pregnancy Related Stroke Hematological Disorders Preeclampsia Gestational Diabetes Post-Partum Period Race Age older than 35 y.o. Other

Hematological Disorders Anemia may result from blood loss that results in cerebral hypoperfusion Thrombocytopenia (low platelet count) Sickle Cell Disease

Pre-eclampsia Pre-eclampsia is a form of pregnancy-associated high blood pressure and protein in the mother’s urine Increase risk associated with 1 st pregnancy, adv. maternal age, black heritage and past hx: DM & HBP) Occurs in about 5 to 7 % of all pregnancies Some research suggests that women who develop pre-eclampsia have a 60 per cent > risk of non- pregnancy-related ischemic stroke 1 out of 200 women who have preeclampsia, blood pressure becomes high enough to have seizures; this condition is called eclampsia

Gestational Diabetes Gestational Diabetes is the inability of the body to process carbohydrates during pregnancy. All pregnant women should be screened for gestational diabetes during their pregnancy In many cases blood glucose levels return back to the pre-pregnancy state after delivery Diabetes is a risk factor for stroke

Post-Partum Period In thromboembolic disease blood clots form in the vessels. This risk of developing thromboembolic disease is increased for about 6 to 8 weeks after delivery. Most complications results from injuries that occur during delivery. The risk is greater after a cesarean section than after vaginal delivery In one study (NEJM) the extremely high relative risk of stroke during the postpartum period is likely the result of a decrease in blood volume or the rapid changes in hormonal status or the hemodynamic, coagulative or vessel-wall changes

Race Black women had the highest risk of stroke (52.5 per 100,000 deliveries) Hispanic women (26.1 per 100,000 deliveries) White women (31.7 per 100,000 deliveries)

Age > 35 y.o. The risk of stroke generally increases with age The risk increased dramatically among women aged 35 to 39 years (58.1 per 100, 000 deliveries) The highest risk among women aged 40 years and older (90.5 per 100,000 deliveries)

Other Cocaine abuse Smoking Hyperemesis Transfusion Cardiac

Management Venous Thrombosis Pregnant women: LMWH or unfractionated heparin for DVT. Coumadin is usually contraindicated. Post-Partum women: LMWH for 7 to 10 days may be followed by Coumadin for 3 to 6 months.

Management cont’d: Stroke and Pregnancy Antiplatelet therapy Heparin therapy Thrombolysis (the safety of thrombolysis in acute ischemic stroke during pregnancy remains unproven)

Risk of Stroke Recurrence The overall risk is small Approximate risk of recurrent stroke of 1%= in the following 12 months and 2.3% within 5 years

Case Study See hand-out

Cerebral Venous Sinus Thrombosis Is a rare from of thrombosis (blood clot) Affecting the dural venous sinuses which drains blood from the brain Symptoms include: headaches, any of the symptoms of stroke, seizures, abnormal vision, and raised intracranial pressure Risk factors: Pregnancy, thrombophilia, birth control pill, chronic inflammatory diseases Treatment: anticoagulants medications and/or tPa

Final Message … Although uncommon, the development of stroke and pregnancy should be managed in a specialized setting that can incorporate the expertise of obstetrics, neurology, neuro- radiology and rehabilitation services