Stroke is common in pregnancy. All physicians and obstetricians caring for pregnant women should be familiar with symptoms of stroke, as well as its diagnosis and treatment. This presentation gives an overview about the latest management of stroke in pregnant women.

1. WHEN STROKE STRIKES
PREGNANCY
DR SUDHIR KUMAR MD DM
CONSULTANT NEUROLOGIST
APOLLO HOSPITALS, HYDERABAD

2. DOES STROKE STRIKE PREGNANCY?
• Yes, it does strike. Incidence is 25-34 cases of
stroke per 100,000 deliveries (incidence in
non-pregnant women in 15-44 yr age is 11 per
100,000 women) (3 times more common)
• Stroke accounts for 12% of maternal deaths
• It also accounts for significant fetal mortality
and morbidity.

3. RISK FACTORS FOR PREGNANCY-
RELATED STROKE
• Hypertensive disorders of pregnancy
• Diabetes, valvular heart disease,
hypercoagulable disorders, lupus, tobacco use
and smoking, migraines
• Hyperemesis gravidarum, anemia, PPH,
infection, age >35 years (OR for stroke: 2)

4. SYMPTOMS OF STROKE
• Headache
• Hemiparesis
• Aphasia
• Sensory loss on one half of body
• Field defect
• Ataxia

5. DIAGNOSIS OF STROKE
• CT Brain- risk of radiation exposure; however,
with head CT, the radiation exposure to fetus
is little.
• MRI Brain without contrast is safe and can be
done at any gestational age.
• MRI BRAIN: SAFE
• GADOLINIUM CONTRAST: AVOID
• CT SCAN: AVOID

6. IV THROMBOLYSIS
• Tissue plasminogen activator is the drug of
choice in first 4.5 hours after ischemic stroke
• tPA does not cross placenta, so, probably safe
in pregnancy.
• No teratogenicity in animal studies,
• No randomized trials in pregnancy
• Complication rates in case reports similar to
non-pregnant women

7. SECONDARY STROKE PREVENTION
• Aspirin- daily low dose aspirin (81 mg/day) is
recommended in pregnant women with
moderate-high risk for developing pre-
eclampsia (to be started between 12-28 weeks
of gestation). Safe in first trimester too
• Clopidogrel- generally avoid
• Warfarin- avoid
• LMW Heparin- safe

8. CASE
• 23-year old lady, 10 weeks gestation
• Presented with severe headache, vomiting
and one episode of GTCS
• Had hyperemesis gravidarum
• O/E-Optic fundi-papilledema; Left hemiparesis

9. MRI/MRV

10. CEREBRAL VENOUS SINUS
THROMBOSIS (CVST)
• Treated with heparin
• Antiepileptics also started
• Patient improved

11. CASE
• 26-year old nulliparous woman, at 38 weeks
gestation presented with severe headache,
blurred vision, one episode of seizure and
altered sensorium of 2 days duration
• BP was 210/110 mmHg
• Peripheral edema+
• LDH was elevated

12. MRI BRAIN

13. POSTERIOR REVERSIBLE
ENCEPHALOPATHY SYNDROME (PRES)
• Treated with anti-hypertensive and anti-
epileptic medications
• Good short-term and long-term outcome.
• MRI abnormalities disappear on follow up
imaging.

14. CONCLUSIONS
• Stroke is common in pregnancy
• MRI brain (without gado contrast) is the
imaging modality of choice
• Thrombolysis is safe
• Heparin is safe but avoid warfarin
• Aspirin is safe, but avoid clopidogrel.
• Watch out for CVST, PRES and RCVS.

15. COMMENTS/QUERIES?
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