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STROKE STROKE Presentation Transcript

  • 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
    • 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
  • 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 1 st 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
  • 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, neuro-radiology and rehabilitation services