STROKE &

PREGNANCY

By Judith Barnaby, Stroke CNSReviewed 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 100 000

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 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 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