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 physiologic...
Statistics
 Stroke is the second leading cause of death of
women in Canada and the United States
 According to Jaigobin ...
Statistics Cont’d:
 Pregnancy related stroke in the UK: 11 to 26 deliveries per 100
000
 Approx. 8% to 15% of pregnancy ...
Physiological Changes Associated
with Pregnancy
 Hypercoagulable state is characteristic of
pregnancy
1. Marked increase ...
Risk Factors for Pregnancy Related
Stroke
 Hematological Disorders
 Preeclampsia
 Gestational Diabetes
 Post-Partum Pe...
Hematological Disorders
 Anemia may result from blood loss that
results in cerebral hypoperfusion
 Thrombocytopenia (low...
Pre-eclampsia
 Pre-eclampsia is a form of pregnancy-associated
high blood pressure and protein in the mother’s urine
 In...
Gestational Diabetes
 Gestational Diabetes is the inability of the
body to process carbohydrates during
pregnancy.
 All ...
Post-Partum Period
 In thromboembolic disease blood clots form in the
vessels.
 This risk of developing thromboembolic d...
Race
 Black women had the highest risk of stroke
(52.5 per 100,000 deliveries)
 Hispanic women (26.1 per 100,000 deliver...
Age > 35 y.o.
 The risk of stroke generally increases with
age
 The risk increased dramatically among
women aged 35 to 3...
Other
 Cocaine abuse
 Smoking
 Hyperemesis
 Transfusion
 Cardiac
Management
Venous Thrombosis
 Pregnant women: LMWH or unfractionated
heparin for DVT. Coumadin is usually
contraindicated...
Management cont’d:
Stroke and Pregnancy
 Antiplatelet therapy
 Heparin therapy
 Thrombolysis (the safety of thrombolysi...
Risk of Stroke Recurrence
 The overall risk is small
 Approximate risk of recurrent stroke of 1%= in
the following 12 mo...
Case Study
 See hand-out
Cerebral Venous Sinus Thrombosis
 Is a rare from of thrombosis (blood clot)
 Affecting the dural venous sinuses which
dr...
Final Message …
 Although uncommon, the development of
stroke and pregnancy should be managed in
a specialized setting th...
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STROKE

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STROKE

  1. 1. STROKE & PREGNANCY By Judith Barnaby, Stroke CNS Reviewed by Dr. Bayer, Stroke Neurologist, St. Michael’s Hospital
  2. 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. 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. 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. 5. Physiological Changes Associated with Pregnancy  Hypercoagulable state is characteristic of pregnancy 1. 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 2. 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. 6. Risk Factors for Pregnancy Related Stroke  Hematological Disorders  Preeclampsia  Gestational Diabetes  Post-Partum Period  Race  Age older than 35 y.o.  Other
  7. 7. Hematological Disorders  Anemia may result from blood loss that results in cerebral hypoperfusion  Thrombocytopenia (low platelet count)  Sickle Cell Disease
  8. 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. 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. 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. 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. 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. 13. Other  Cocaine abuse  Smoking  Hyperemesis  Transfusion  Cardiac
  14. 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. 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. 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. 17. Case Study  See hand-out
  18. 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. 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

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