Hemorrhagic Stroke In Pregnancy

Vidhu Krishnan

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Strokes in Pregnancy

Increased Risk in Pregnancy and Puerperium

? Precise Pathophysiology.

Hemorrhagic Stroke rarer

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Case Report39 years , G7P2-1M4 32/40

 SVB 9 years ago

4 First Trimester Miscarriages.

FDIU at 22/40

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Post Partum: Thrombus in the superficial tributary veins of the right calf.

Enoxaparin – 6 weeks

Autopsy: Foetal thrombotic vasculopathy .

Current Pregnancy : Uncomplicated

Therapeutic Clexane and Aspirin

GDM on Insulin

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Initial presentation: 3 day history of Headache and intractable vomiting

Treated with anti emetic, fluids and panadol.

• Diagnosis of the intracranial bleed :second presentation .

Second Presentation : Neurological symptoms

Facial droop, Tongue Deviation

Decreased Power and weakness left side.

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Investigations

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Management• Blood pathology

Normal Platelets (273). Normal Coagulation profile (INR1.0, Anti Xa 0.7U)

• Her LMWH and aspirin stopped

• Intravenous steroids ,platelets (for reversal of clexane) then oral dexamethasone for management of her ICH.

• Obstetric management: Steroids for foetal maturity .

• Ultrasound : Well-grown baby i normal dopplers and amniotic fluid index.

• Extensive Rehabilitation

• Repeat CT scan

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Management

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MRI

• GA, Elective Caesarean section at 38/40 weeks

Baby: Cephalic , 2720g

Currently : Independent with personal care and staying with her parents

DiscussionIncidence of strokes during pregnancy : varies

from region – region,5 – 67 per 100000 deliveries .

Mothers who survive a stroke :Residual neurological deficit varying from 42- 63% .

Maternal mortality :26%

Foetal mortality being 12%

Peri partum – Highest risk.

Strokes secondary to AVM : 7- 17%

Ref :Khan, M. and M. Wasay, Haemorrhagic strokes in pregnancy and puerperium. Int J Stroke, 2013. 8(4): p. 265-72.

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EpidemiologyRisk Factors (Pregnancy related)

Advanced maternal age

Pre eclampsia / Eclampsia

Coagulopathy

• Etiology

Pre Eclampsia/ Eclampsia

Aneurysmal Rupture

Bleeding from AVM

Cortical Venous thrombosis.

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Enoxaparin in Pregnancy

Anti coagulant of choice.

• Safe.

• Pregnancy complications like venous thromboembolism, recurrent pregnancy loss, pre eclampsia and placental abruption.

• Monitoring :Anti Xa 0.2 to 0.6 units/mL

Ref :Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines,” Chest, 2012,

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Clinical FeaturesHeadache- Sudden onset

Vomiting

Blurred vision

Focal Neurological deficits

Seizures

Altered sensorium

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Management

Investigations: CT /MRI.

General Management

Delivery

Prognosis and Recurrance.

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Summary

Hemorrhagic Stroke in Pregnancy : Rare

Hypertension

Principles of management

Vaginal delivery preferred.

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References 1. Sharshar, T., et al., Incidence and Causes of Strokes Associated With Pregnancy and

Puerperium: A Study in Public Hospitals of Ile de France. Stroke, 1995. 26(6): p. 930-936.

2. Walsh, J., et al., Maternal cerebrovascular accidents in pregnancy: incidence and outcomes. Obstetric Medicine: The Medicine of Pregnancy, 2010. 3(4): p. 152-155.

3. Tang, S.C. and J.S. Jeng, Management of stroke in pregnancy and the puerperium. Expert Rev Neurother, 2010. 10(2): p. 205-15.

4. Khan, M. and M. Wasay, Haemorrhagic strokes in pregnancy and puerperium. Int J Stroke, 2013. 8(4): p. 265-72.

5. Le Roux, P., et al., Race against the clock: overcoming challenges in the management of anticoagulant-associated intracerebral hemorrhage. J Neurosurg, 2014. 121 Suppl: p. 1-20.

6. Bates, S.M., et al., Venous thromboembolism, thrombophilia, antithrombotic therapy, and pregnancy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest, 2008. 133(6 Suppl): p. 844s-886s.

7. Vucic, N., et al., [Thrombophilia, preeclampsia and other pregnancy complications]. Acta Med Croatica, 2009. 63(4): p. 297-305.

8. Laurent, P., et al., Low molecular weight heparins: a guide to their optimum use in pregnancy. Drugs, 2002. 62(3): p. 463-77.