STROKE & PREGNANCYBy Judith Barnaby, Stroke CNSReviewed by Dr. Bayer, Stroke Neurologist, St. Michaels Hospital

Learning ObjectivesTo identify pertinent research statistics that pertain to the subject matterTo review physiological changes associated with pregnancyTo recognize the risk factors for pregnancy as it relates to strokeTo discuss the management therapiesTo review a case study (stroke and pregnancy): Case analysis and application of theoryTo review cerebral venous sinus thrombosis

StatisticsStroke is the second leading cause of death of women in Canada and the United StatesAccording 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 eventWashington 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 Contd:Pregnancy related stroke in the UK: 11 to 26 deliveries per 100 000Approx. 8% to 15% of pregnancy related stroke victims dieC-Section deliveries (3 to 12 times higher risk) than vaginal deliveriesA 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 PregnancyHypercoagulable state is characteristic of pregnancy

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 labourDeep 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 DisordersPreeclampsiaGestational DiabetesPost-Partum PeriodRace Age older than 35 y.o.Other

Hematological DisordersAnemia may result from blood loss that results in cerebral hypoperfusionThrombocytopenia (low platelet count)Sickle Cell Disease

Pre-eclampsia

Pre-eclampsia is a form of pregnancy-associated high blood pressure and protein in the mothers urineIncrease risk associated with 1st 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 stroke1 out of 200 women who have preeclampsia, blood pressure becomes high enough to have seizures; this condition is called eclampsia

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

Post-Partum PeriodIn 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 deliveryIn 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

RaceBlack 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 ageThe 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)

OtherCocaine abuseSmokingHyperemesisTransfusionCardiac

ManagementVenous 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 contd:Stroke and Pregnancy

Antiplatelet therapyHeparin therapyThrombolysis (the safety of thrombolysis in acute ischemic stroke during pregnancy remains unproven)

Risk of Stroke RecurrenceThe overall risk is smallApproximate risk of recurrent stroke of 1%= in the following 12 months and 2.3% within 5 years

Case StudySee hand-out

Cerebral Venous Sinus ThrombosisIs a rare from of thrombosis (blood clot)Affecting the dural venous sinuses which drains blood from the brainSymptoms include: headaches, any of the symptoms of stroke, seizures, abnormal vision, and raised intracranial pressureRisk 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