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 3 rd 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?