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 Estimates 4-11 / 100,000 deliveries

Incidence

Results (antenatal) 1.5 cases per 100, infarcts 0.6 haemorrhagic Note event cluster around time of birth

Maternal changes Haemostasis – Overall balance = pro-coagulant – Especially 3 rd 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:

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?