pregnancy and stroke dr kneale metcalf consultant stroke physician nnuhft
TRANSCRIPT
Pregnancy and Stroke
Dr Kneale MetcalfConsultant 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
• Estimates 4-11 / 100,000 deliveries
Incidence
Results (antenatal)
• 1.5 cases per 100,000• 0.9 infarcts• 0.6 haemorrhagic
• Note event cluster around time of birth
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
Risk factors
• Hypertension• Diabetes• Heart disease• Sickle cell• Thrombolphilia
Risk factors
• Alcohol• Smoking• Substance abuse• Age (>35y)• Migraine
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%
Pregnancy specific risks
• Caeserean• Pre / Eclampsia– Hypertension– Proteinuria– Oedema– Then ….headache, confusion, seizures
• Amniotic fluid embolism• Post partum cerebral angiopathy• Peripartum Cardiomyopathy
Presentation
• Standard but….– Presented with reduced consciousness or collapse• 30% ischaemic• 37% haemorrhagic
– Presented with seizure in 33% haemorrhagic strokes
Sub classification of antenatal strokes
Imaging considerations
• CT – Radiation– Definitely avoid in first few weeks
• CT perfusion– Radiation dose
• MRI– Noise– Vibration– Magnetic field– Avoid Gadalinium
Treatment
• Haemorrhage – standard• Venous Sinus Thrombosis – standard
• Remember risks versus benefit, including the foetus
• Infarct – controversial. 11 case reports using Alteplase
• Legal situation??
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??
Prevention
• Little guidance• Consider – Pregnant past Hx stroke– thrombophilia – Cardiac abnormaities
• Antiplatelet• LMWH
Stroke, 2013;44:864-868
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
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??
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
References
Any questions?