STROKE & PREGNANCY

1. STROKE & PREGNANCY By Judith Barnaby, Stroke CNS Reviewed by Dr. Bayer, Stroke Neurologist, St. Michael’s Hospital

2. 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

3. 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

4. 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)

5. Physiological Changes Associated with Pregnancy • Hypercoagulable 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 labour • 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

6. Risk Factors for Pregnancy Related Stroke • Hematological Disorders • Preeclampsia • Gestational Diabetes • Post-Partum Period • Race • Age older than 35 y.o. • Other

7. Hematological Disorders • Anemia may result from blood loss that results in cerebral hypoperfusion • Thrombocytopenia (low platelet count) • Sickle Cell Disease

8. 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

9. 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

10. 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

11. 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)

12. 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)

13. Other • Cocaine abuse • Smoking • Hyperemesis • Transfusion • Cardiac

14. 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.

15. Management cont’d: Stroke and Pregnancy • Antiplatelet therapy • Heparin therapy • Thrombolysis (the safety of thrombolysis in acute ischemic stroke during pregnancy remains unproven)

16. 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

17. Case Study • See hand-out

18. 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

19. 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