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Stroke in Pregnancy
Aka: Stroke in Pregnancy, Cerebrovascular Accident in Pregnancy, CVA in Pregnancy
- See Also
- Cerebrovascular Accident Risk in Women
- Cerebrovascular Accident
- CVA Management
- Transient Ischemic Attack
- CVA Thrombolysis
- CVA Blood Pressure Control
- Prevention of Ischemic Stroke
- Anticoagulation in Ischemic Stroke
- Epidemiology
- Incidence: 10-30 per 100,000 pregnancies in U.S.
- Risk Factors
- See Cerebrovascular Accident Risk in Women
- Preeclampsia or Eclampsia
- Pregnancy hematologic disorders (e.g. HELPP Syndrome)
- Cesarean Pregnancy
- Congenital Heart Defects
- Gestational Diabetes
- Migraine Headaches especially with aura (see above)
- Migraine Headache may cause stroke or stroke mimic
- Differential Diagnosis
- See Cerebrovascular Accident (includes stroke mimics)
- Reversible Cerebral Vasoconstriction Syndrome
- Imaging
- CT Head and CT Angiogram Head and Neck (standard CVA Evaluation)
- Radiation exposure to fetus is low (0.01 rads)
- Iodinated contrast appears safe (with low risk of transient Thyroid dysfunction)
- Bourjelly (2010) Radiology 256(3): 744-50 [PubMed]
- MRI Brain
- Evaluate for CVA not identified on CT (or perform MRI instead of CT if delayed presentation >12-24 hours)
- Do not use gadolinium contrast in pregnancy
- MRA Brain may be performed instead of CTA if no delays
- Management
- CVA Thrombolysis (tPA)
- Similar indications and Consultation with Stroke Neurology for presentations <3 to 4.5 hours and significant deficit
- tPA is a large molecule that does not cross placenta
- Thrombolytics risk signficant uterine bleeding
- Intervention Radiology and Neurology
- Similar indications for large vessel Occlusion (esp. <12 hours)
- Risk of bleeding with Glycoprotein IIB/IIIA Inhibitor often used in perioperative period and for vessel perforation
- Stent placement typically requires longer term use of Platelet ADP Receptor Antagonist (e.g. Plavix)
- Risk of Postpartum Hemorrhage
- Antiplatelet Therapy in CVA and TIA
- Aspirin 81 mg orally daily may be used (avoid full dose Aspirin in pregnancy)
- References
- Pensa and Roth in Herbert (2020) EM:Rap 20(10): 6-7
- Grear (2013) Clin Obstet Gynecol 56(2): 350-9 +PMID:23632643 [PubMed]