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Pregnancy and Stroke

Pregnancy and Stroke. Dr Kneale Metcalf Consultant Stroke Physician NNUHFT. Overview. Incidence Risk factors Management Outcome Avoid. Incidence. Varies according to study Depends on whether you include post-partum events Some studies pre date imaging

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Pregnancy and Stroke

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  1. Pregnancy and Stroke Dr Kneale Metcalf Consultant Stroke Physician NNUHFT

  2. Overview • Incidence • Risk factors • Management • Outcome • Avoid

  3. Incidence • Varies according to study • Depends on whether you include post-partum events • Some studies pre date imaging • Estimates 4-11 / 100,000 deliveries

  4. Incidence

  5. Results (antenatal) • 1.5 cases per 100,000 • 0.9 infarcts • 0.6 haemorrhagic • Note event cluster around time of birth

  6. Maternal changes • Haemostasis • Overall balance = pro-coagulant • Especially 3rd trimester • Return to normal 3 weeks after delivery • Haemodynamic • Increased cardiac output • Initial reduced BP, then increases to delivery

  7. Risk factors • Hypertension • Diabetes • Heart disease • Sickle cell • Thrombolphilia

  8. Risk factors • Alcohol • Smoking • Substance abuse • Age (>35y) • Migraine

  9. Risk factors (UK study) • Hx migraine (OR 8.5) • Hx gestational DM (OR 26.8) • Hx pre or eclampsia (OR 7.7) • Risk stroke – every mmHg highest recorded during pregnancy • Systolic = 3% • Diastolic = 8%

  10. Pregnancy specific risks • Caeserean • Pre / Eclampsia • Hypertension • Proteinuria • Oedema • Then ….headache, confusion, seizures • Amniotic fluid embolism • Post partum cerebral angiopathy • Peripartum Cardiomyopathy

  11. Presentation • Standard but…. • Presented with reduced consciousness or collapse • 30% ischaemic • 37% haemorrhagic • Presented with seizure in 33% haemorrhagic strokes

  12. Sub classification of antenatal strokes

  13. Imaging considerations • CT • Radiation • Definitely avoid in first few weeks • CT perfusion • Radiation dose • MRI • Noise • Vibration • Magnetic field • Avoid Gadalinium

  14. Treatment • Haemorrhage – standard • Venous Sinus Thrombosis – standard • Remember risks versus benefit, including the foetus • Infarct – controversial. 11 case reports using Alteplase • Legal situation??

  15. Real world • Remember your differential….. • Migraine • Eclampsia • Remember venous sinus thrombosis • If very bad ?intervention • Get the best imaging you can safely (MRI) • Get the Obstetricians down ASAP • Communicate ++++++ • Consider the baby all the time • Each case will have to be judged on merit • Legal……is doing nothing safe??

  16. Prevention • Little guidance • Consider • Pregnant past Hx stroke • thrombophilia • Cardiac abnormaities • Antiplatelet • LMWH

  17. Stroke, 2013;44:864-868

  18. Summary of discussion • Essentially an evidence free zone • Alteplase not licenced in pregnancy • All respondents were from advanced stroke centres • Possibility of endovascular intervention • Alteplase doesn’t cross placental barrier • Disabling stroke is a disaster • More info the better (imaging etc.) • Time is brain

  19. All agreed • IV thrombolysis possibly with thrombectomy • But… • They had full MRI imaging and vascular imaging • On site warmed up vascular lab • Long way from the EoE – but what of the future??

  20. Summary • May we never have a case! • Be as sure as you can be it’s a stroke • Don’t be too petrified to treat

  21. References

  22. Any questions?

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