Pocket ObGyn – Stroke in Pregnancy
See Abbreviations
Epidemiology and Pathophysiology
- Stroke in Preg = 4–26/100000 (3–10/100000, nonpregnant women)
- Most common in 3rd trimester or puerperium, but also in PP (8.7´ for ischemic stroke; 24´ for hemorrhagic stroke). ~10% of all mat
- Most common cause of stroke in Preg is preeclampsia/eclampsia
- due to hypercoagulable state of Preg; cerebral endothelial dysfxn
Diagnosis (Obstet Med 2011;4:2)
- Acute: Hx, PE (listen for murmurs, carotid & subclav bruits, & look for signs of periph emboli). Urgent CT, noncontrast, to rule out hemorrhage, followed by CT MRI/MRA w/ gadolinium. Doppler scan of the LE ® if negative, then MRV.
- Risk factors: Hypercoagulable state: Lupus anticoagulant, anticardiolipin antibodies, anti-b2 glycoprotein, Factor V Leiden, prothrombin, prot C & S, antithrombin Peripartum cardiomyopathy.
Post reversible Encephalopathy Syn (Mayo Clin Proc 2010;85:427)
- Related to cerebral autoregulation & endothelial Seen in preeclampsia.
- Features: HA, altered consciousness, visual disturbances (hemianopia, visual hallucinations), seizures (often presenting manifestation)
- radiology: Symmetrical white matter edema in the post cerebral hemispheres, rarely seen on CT, but better depicted on MRI
- rx: Lower BP, fully reversible w/i days to weeks
Postpartum Cerebral Angiopathy (Am J Obstet Gynecol 2004;191:375)
- Reversible cerebral vasoconstriction syndromes
- Timeline: Few days post Features: Thunderclap HA, vomiting, seizures.
- radiology: Multifocal segmental narrowing of cerebral arteries, resolution in 4–6 w
- CSF nml
Cerebral Aneurysm rupture and SAH (N Engl J Med 1996;335:768)
- Relative risk of intracerebral hemorrhage during Preg & up to 6 w PP is 6 times that of the nonpregnant pt
- Surgical rx after SAH during Preg improves mat & fetal outcomes
- Favor vaginal deliv unless aneurysm is diagnosed at term or there has been neurosurgical intervention w/i the week before deliv