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WHEN STROKE STRIKES
PREGNANCY
DR SUDHIR KUMAR MD DM
CONSULTANT NEUROLOGIST
APOLLO HOSPITALS, HYDERABAD
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.
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)
SYMPTOMS OF STROKE
• Headache
• Hemiparesis
• Aphasia
• Sensory loss on one half of body
• Field defect
• Ataxia
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
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
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
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
MRI/MRV
CEREBRAL VENOUS SINUS
THROMBOSIS (CVST)
• Treated with heparin
• Antiepileptics also started
• Patient improved
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
MRI BRAIN
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.
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.
COMMENTS/QUERIES?
• Whatsapp: 98 661 93 953
• Email: drsudhirkumar@yahoo.com
• Facebook:
www.facebook.com/bestneurologist/

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WHEN STROKE STRIKES PREGNANCY

  • 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
  • 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
  • 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? • Whatsapp: 98 661 93 953 • Email: drsudhirkumar@yahoo.com • Facebook: www.facebook.com/bestneurologist/