SPECIAL TOPICS IN STROKE CARE:
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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
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 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
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