How is ischemic stroke treated during pregnancy?

Updated: Aug 20, 2019
  • Author: Carmel Armon, MD, MSc, MHS; Chief Editor: Stephen A Berman, MD, PhD, MBA  more...
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Answer

Tissue-type plasminogen activator (tPA) is a category C agent in pregnancy. Its effects on humans and animals during pregnancy have not been adequately evaluated, and at this point, it is considered to be contraindicated. [72, 75] (See Thrombolytic Therapy in Stroke.)However, recent reports of its use have led to reconsideration of this position. TPA is a large molecule (7200kDa) and does not cross the placental barrier. There are no teratogenic effects in short-term studies in animals, no tumorigenicity in rodents, no mutagenicity or production of chromosomal aberrations in human lymphocytes, and in rabbits no maternal or fetal toxicity at 1mg/kg dosage. Three publications reporting on treatment of 8 mothers provided encouraging outcome data. [77, 78, 79] There was good neurological recovery in most mothers. One patient also had IA angioplasty, which led to dissection, amalignant MCA infarct, and death. One patient sustained an intrauterine hematoma that was drained. Fetal outcome in 5 babies was good. In two early cases medical termination of pregnancy was opted for, and one child died with the mother.

The current recommendations, based on expert opinion, [80, 81, 82] are that treatment decisions should be made balancing the natural history – prognosis without tPA treatment and the benefit of treatment - taking into consideration the risks of treatment.

Use of IV tPA can be considered in a pregnant patient. The chief risk to the mother is a symptomatic intracranial bleed, which is lower in individuals < 60 years: 2.8%, and a bleed eslewhere. To date, there has not been a demonstrated risk to the fetus with IV tPA. Despite in vitro concerns, iodinated contrast seems safe to use during pregnancy. IV contrast does not pose a risk to the fetus. [83, 84, 85]

Although other interventional techniques are being developed to treat acute stroke, information about treating the pregnant patient with stroke with these modalities is limited. When any of these modalities is considered in a pregnant woman, the known risks of withholding treatment must be balanced against the unknown risks of treatment.

The stage of the pregnancy (ie, the gestational age) likely factors into the considerations. From a dosing standpoint, targeted intra-arterial treatment might be safer than other routes, but it presents radiation risks to the fetus because of the use of x-ray fluoroscopy during the treatment.


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