1. Hemorrhagic Stroke In Pregnancy
Vidhu Krishnan

2. Strokes in Pregnancy Increased Risk in Pregnancy and Puerperium
? Precise Pathophysiology.
Hemorrhagic Stroke rarer

3. Case Report 39 years , G7P2-1M4 32/40 SVB 9 years ago
4 First Trimester Miscarriages.
FDIU at 22/40

4. Post Partum: Thrombus in the superficial tributary veins of the right calf.
Enoxaparin – 6 weeks
Autopsy: Foetal thrombotic vasculopathy .
Current Pregnancy : Uncomplicated
Therapeutic Clexane and Aspirin
GDM on Insulin

5. Initial presentation: 3 day history of Headache and intractable vomiting
Treated with anti emetic, fluids and panadol.
Diagnosis of the intracranial bleed :second presentation .
Second Presentation : Neurological symptoms
Facial droop, Tongue Deviation
Decreased Power and weakness left side.

6. Investigations

7. Management Blood pathology Her LMWH and aspirin stopped
Normal Platelets (273). Normal Coagulation profile (INR1.0, Anti Xa 0.7U)
Her LMWH and aspirin stopped
Intravenous steroids ,platelets (for reversal of clexane) then oral dexamethasone for management of her ICH.
Obstetric management: Steroids for foetal maturity .
Ultrasound : Well-grown baby i normal dopplers and amniotic fluid index.
Extensive Rehabilitation
Repeat CT scan
. Post her presentation to the tertiary hospital; the ICU team, neurosurgery and obstetric teams managed her jointly. Her LMWH and aspirin were stopped and she was MANAGED CONSERVATIVELY FOR HER ich, wHICH INCLUDED intravenous steroids, platelets (reversal of clexane) and then oral dexamethasone.sHE HAD A 5 DAY ICU stay.Clinically, the patient continued to have GCS of 15, weakness persisting on the left side of the face and being unable to mobilise.
 In terms of her obstetric management, she had steroids for foetal maturity and serial ultrasound for growth.showed a well-grown baby in breech presentation with normal dopplers and amniotic fluid index. Her blood parameters remained within normal limits, including the coagulation profile. Anti thrombin, Anti phospholipid antibody, Protein S, Factor 5 leiden markers were negative.

8. Management

10. MRI
GA, Elective Caesarean section at 38/40 weeks
Baby: Cephalic , 2720g
Currently : Independent with personal care and staying with her parents

11. Discussion
Incidence of strokes during pregnancy : varies from region – region,5 – 67 per deliveries .
Mothers who survive a stroke :Residual neurological deficit varying from % .
Maternal mortality :26%
Foetal mortality being 12%
Peri partum – Highest risk.
Strokes secondary to AVM : 7- 17%
Ref :Khan, M. and M. Wasay, Haemorrhagic strokes in pregnancy and puerperium. Int J Stroke, (4): p

12. Epidemiology Risk Factors (Pregnancy related) Etiology
Advanced maternal age
Pre eclampsia / Eclampsia
Coagulopathy
Etiology
Pre Eclampsia/ Eclampsia
Aneurysmal Rupture
Bleeding from AVM
Cortical Venous thrombosis.

13. Enoxaparin in Pregnancy
Anti coagulant of choice.
Safe.
Pregnancy complications like venous thromboembolism, recurrent pregnancy loss, pre eclampsia and placental abruption.
Monitoring :Anti Xa 0.2 to 0.6 units/mL
Ref :Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines,” Chest, 2012,

14. Clinical Features Headache- Sudden onset Vomiting Blurred vision
Focal Neurological deficits
Seizures
Altered sensorium

15. Management Investigations: CT /MRI. General Management Delivery
Prognosis and Recurrance.

16. Summary Hemorrhagic Stroke in Pregnancy : Rare Hypertension
Principles of management
Vaginal delivery preferred.

17. References
1. Sharshar, T., et al., Incidence and Causes of Strokes Associated With Pregnancy and Puerperium: A Study in Public Hospitals of Ile de France. Stroke, (6): p
2. Walsh, J., et al., Maternal cerebrovascular accidents in pregnancy: incidence and outcomes. Obstetric Medicine: The Medicine of Pregnancy, (4): p
3. Tang, S.C. and J.S. Jeng, Management of stroke in pregnancy and the puerperium. Expert Rev Neurother, (2): p
4. Khan, M. and M. Wasay, Haemorrhagic strokes in pregnancy and puerperium. Int J Stroke, (4): p
5. Le Roux, P., et al., Race against the clock: overcoming challenges in the management of anticoagulant- associated intracerebral hemorrhage. J Neurosurg, Suppl: p
6. Bates, S.M., et al., Venous thromboembolism, thrombophilia, antithrombotic therapy, and pregnancy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest, (6 Suppl): p. 844s-886s.
7. Vucic, N., et al., [Thrombophilia, preeclampsia and other pregnancy complications]. Acta Med Croatica, (4): p
8. Laurent, P., et al., Low molecular weight heparins: a guide to their optimum use in pregnancy. Drugs, (3): p