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Stroke in Pregnancy and the Postpartum Period


 

We found no correlation among trial of labor, mode of delivery, and the type of stroke suffered or outcome. We found no association with anesthesia type and stroke.

Presenting symptoms included headache in 16 patients, neurologic signs (motor weakness, blindness, aphasia, or coma) in 12, seizures in 11, and visual changes in 10.

Two deaths occurred, one associated with a cocaine-related hemorrhage and the other with a ruptured anatomical malformation.

A review of the medical records suggested that no case could have been prevented by the recognition of risk factors or alternative medical care.

In the diagnosis of stroke, the history and physical examination are critically important, although imaging is often needed to further clarify the diagnosis and distinguish stroke type and features.

The two basic causes of stroke are ischemia and postpartum hemorrhage.

Ischemia (infarction) may be caused by vascular thrombosis, embolism, vasospasm, or marked reduction in systemic perfusion pressure (hypotensive ischemic injury).

Postpartum Hemorrhage

Postpartum hemorrhage is divided into intracerebral or subarachnoid hemorrhage. Intracerebral hemorrhage refers to bleeding directly into brain tissue from small intracerebral vessels, caused by severe hypertension and/or coagulopathy or vascular malformations. In subarachnoid hemorrhage, blood seeps onto the brain's surface and merges with ambient cerebrospinal fluid, often as a result of a ruptured aneurysm or arteriovenous malformation.

Strokes of arterial origin most often occur during the second or third trimester, or within the first few weeks post partum. Symptoms include acute decompensation of cortical function, aphasia, hemiplegia, and/or hemianopsia.

Strokes of venous origin, on the other hand, are most likely to occur from 3 days to 4 weeks after delivery. Common symptoms include a severe, progressive headache; papilledema; weakness; convulsions; and/or aphasia.

Our review of 20 postpartum cases involved cerebritis (12 women), venous infarction (7 women), arterial infarction (6), intracerebral hemorrhage (5), and atrophy (1).

Among the 18 patients who survived, 12 suffered no residual defects, whereas others suffered hemiparesis, aphasia, or weakness. Although not statistically significant, there appeared to be a trend toward more adverse outcomes in women who suffered intracerebral hemorrhage vs. cerebral infarction.

Neuroimaging studies should be performed in any patient with symptoms that may be consistent with stroke. CT is widely available and may be very useful in confirming the diagnosis; however, a negative CT should not rule out further testing in the face of suspicious symptoms and/or physical examination findings. In our series, the initial CT was negative in 3 of 20 patients, with subsequent MRI or MRI angiography required to accurately diagnose stroke and elucidate its features.

Four-vessel traditional angiography, echocardiography, and lumbar puncture are other diagnostic modalities.

Of course, appropriate consultation is an integral part of stroke management, and may include a maternal-fetal medicine specialist as well as neurologists, neurosurgeons, radiologists, anesthesiologists, and later, rehabilitation specialists, social workers, and physical and occupational therapists.

Treatment hinges on protecting salvageable brain tissue; stabilizing the patient and preventing further complications such as aspiration; controlling blood pressure and other physiologic factors; and initiating physical rehabilitation.

As evidenced in our series, young patients have a great capacity for recovery in many cases.

My overall recommendation for stroke management is to admit the patient to labor and delivery, perform a thorough maternal and fetal evaluation, and use a multidisciplinary approach to care throughout.

Order antihypertensive medication if the systolic blood pressure is 160 mm Hg or greater, the diastolic blood pressure is 110 mm Hg or greater, or if the mean arterial pressure is 125 mm Hg or greater. Antiseizure, antiemetic, and anticoagulation medications should be administered as needed.

Neither medications nor surgery should be withheld because of pregnancy.

Deliver the patient in cases of maternal instability or nonreassuring fetal status; labor or rupture of membranes; or gestational age greater than 34 weeks.

When Intervention Is Necessary

At a gestational age of less than 24 weeks, intervention should be guided by the woman's diagnosis and condition.

Between 24 and 32 weeks' gestation, administer steroids for fetal lung maturity and conduct daily reassessments of the maternal and fetal condition with a planned delivery at 34 weeks, or term delivery if circumstances warrant.

Between 33 and 34 weeks, steroids should be administered and the baby delivered.

The nature of the stroke will determine the best course of medical and surgical management for the cerebrovascular event.

When anticoagulation is needed, keep in mind that warfarin crosses the placenta and has been linked to teratogenicity in the first trimester and bleeding complications in the third trimester. Heparin has been associated with thrombocytopenia, osteoporosis, and bleeding disorders, although it does not cross the placenta. After vaginal delivery, I recommend withholding anticoagulation for 6 hours. I recommend withholding anticoagulation for 12 hours following C-section.

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