Transcript SPECIAL TOPICS IN STROKE CARE:

STROKE
&
PREGNANCY
By Judith Barnaby, Stroke CNS
Reviewed by Dr. Bayer, Stroke
Neurologist, St. Michael’s Hospital
Learning Objectives
 To identify pertinent research statistics that pertain to
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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
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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
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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 nonpregnancy-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
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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, neuroradiology and rehabilitation services