Stroke in Pregnancy and the Postpartum Period

When infection is implicated in stroke, antibiotics should be administered along with anticoagulation.

Low-dose aspirin may be sufficient to treat patients with a single episode of transient ischemic attack.

Hypertensive encephalopathy requires intensive management during labor and for 48 hours post partum. Response to antihypertensive therapy confirms the diagnosis. Volume contraction may be present, evidenced by a sharp drop in diastolic blood pressure and a rise in heart rate on standing from the supine position. Normal saline infusion for 24–48 hours may be considered to achieve volume expansion, decrease the activity of the renin-angiotensin-aldosterone axis, and maintain better blood pressure control. Careful attention should be paid to volume status, blood pressure urinary output, electrocardiographic readings, and mental status. Antepartum patients should have continuous fetal monitoring.

Eclampsia is treated with supportive care, including oxygenation; minimization of aspiration and future injuries; and lowering of blood pressure. Magnesium sulfate is used for the prevention of eclamptic seizures, although seizures may persist in 10% of patients. The medication should be maintained throughout labor and for 24 hours post partum.

Disturbances in the fetal heart rate are commonly seen after an eclamptic seizure, although resolution usually occurs within 5–10 minutes. Proceed to cesarean delivery only for obstetric indications, as vaginal delivery is preferred following a seizure.

Labor can be induced with oxytocin or prostaglandins.

Carefully monitor the patient's overall fluid status. These patients may have profound hemoconcentration, which necessitates close hemodynamic monitoring when epidural anesthesia is used and after severe blood loss. Acute blood loss can be a serious complication in hypovolemic patients. Limit fluids to prevent pulmonary edema secondary to capillary leakage.

Thrombolytic therapy with intraarterial recombinant tissue plasminogen activator has been used to treat ischemic stroke in pregnancy. This treatment must be administered within a window of 6 hours or less to be effective.

Course of Treatment

Patients who receive a diagnosis of arteriovenous malformation or aneurysm before hemorrhage should be referred for surgical embolization or clipping, as it is believed that patients with AVM may be at increased risk of bleeding during pregnancy. Patients with AVMs are also prone to bleed during delivery.

Once an intracerebral hemorrhage has occurred, the extent of the bleeding will determine the course of treatment. If the brain stem is compromised, surgical decompression is necessary. Surgery may also be necessary if the bleed is subarachnoid in origin; however, surgery itself may damage overlying normal brain tissue, and surgical morbidity is high.

If the bleeding and the patient are stable, surgery can be avoided. Blood pressure should be well controlled and seizures prevented. Steroids have not proven beneficial.

In summary, I would encourage obstetricians to become well versed in the symptoms of stroke and to have a low threshold for clinical suspicion of such symptoms, which may mimic common complaints of pregnancy.

A rapid diagnosis and close consultation with an interdisciplinary team of colleagues may maximizing outcome in patients suffering one of the most feared and serious complications of pregnancy.

This CT shows the brain of a pregnant woman who had a hemorrhagic stroke.

This MRI shows the brain of a pregnant woman who had an ischemic stroke. Photos courtesy Dr. Baha Sibai

How to Weigh Stroke History, Pregnancy

With enhanced diagnosis and management of stroke, more patients are recovering well. These patients will increasingly seek advice about the risks of subsequent pregnancy.

We recently conducted a review of 35 pregnancies in 23 women with a history of stroke, including 9 pregnancies in 4 women whose previous stroke had occurred during pregnancy or the postpartum period (Am. J. Obstet. Gynecol. 2004;190:1331–4).

Their risk factors for the prior stroke included thrombophilias, sickle cell disease, cardiac malformations, hypertension, oral contraceptive use, cerebral arteriovenous malformations, head trauma, meningitis, endocarditis, and idiopathic etiologies.

Anticoagulation was prescribed in two pregnancies in patients who had a reported history of pregnancy/postpartum stroke. Our findings were reassuring.

There were no recurrent thrombotic episodes during pregnancy or the postpartum period, although one patient required admission to the ICU for uncontrolled hypertension.

This result aligns with findings from another study (Neurology 2000;55:269–74), which found a 1% recurrence rate. The chance of recurrence in patients with thrombophilia is likely higher, perhaps 20%.

It makes sense to prescribe anticoagulation for women at risk of thromboembolic stroke, either low-dose aspirin plus prophylactic doses of unfractionated heparin, or low-molecular-weight heparin.

All women with a history of stroke deserve close monitoring during pregnancy, delivery, and the postpartum period.

Recognizing Stroke Is a Life or Death Issue