Pregnancy and Stroke Risk in Women

Jessica Tate; Cheryl Bushnell

Disclosures

Women's Health. 2011;7(3):363-374. 

In This Article

Treatment of Acute Pregnancy-related Stroke

Treatment of acute arterial stroke in pregnancy is also controversial. Recombinant tissue plasminogen activator (rtPA) is a drug that lyses clot when given intravenously or inta-arterially to patients with acute ischemic stroke. Randomized clinical trial evidence demonstrated that if rtPA is administered within 3 h of ischemic stroke onset in nonpregnant patients, this drug decreases the risk of mortality and improves outcome at 90 days poststroke compared with placebo.[38] However, there is an approximate 6% risk of hemorrhage, and this risk increases with administration greater than 3 h after onset of the stroke symptoms.[38] Thrombolytic drugs can be administered intra-arterially for proximal middle cerebral artery occlusions effectively and relatively safely.[39] In addition, there are devices that have been approved for mechanical thrombectomy, such as the Merci device.[40] or the Penumbra device.[41] In some cases, intra-arterial rtPA can be combined with mechanical thrombectomy. Patients tend to have optimal outcomes if whatever method is used leads to partial or complete recanalization of the occluded artery.

Recombinant tissue plasminogen activator does not cross the placenta and there has been no evidence of teratogenicity in animal studies.[42] It is listed as a category C drug and pregnancy is considered a relative contraindication for administration, but there are multiple case reports of successful use in pregnant women. In one instance, rtPA was given intra-arterially in the third trimester, 5 h after onset of left hemiplegia, with catheter angiogram demonstrating a right middle cerebral artery trunk occlusion.[43] The infant was delivered without complication 3 days later, and at 2-month follow-up the mother had no residual neurologic deficits. Several other case reports and case series have reported successful outcomes after use of thrombolytics for mothers, and in most cases for infants when mothers did not choose elective termination (Table 4).[44–47] Risks and benefits should be carefully weighed, but it appears that thrombolytics can be used both intravenously and intra-arterially in pregnancy with positive outcomes.

There are no clear guidelines for medical management of subarachnoid or ICH in pregnancy. Drugs used on a routine basis in nonpregnant patients, such as mannitol for elevated intracranial pressure, antiepileptics for prevention or management of seizures, and nimodipine for vasospasm, must be utilized with caution in pregnant women. Mannitol may result in fetal hypoxia and acid-base shifts, antiepileptic drugs are associated with varying degrees of teratogenic risk, and nimodipine has been linked with teratogenicity in some animal experiments, but there is minimal data in humans.[19,29] However, ultimately, the use of these agents in critically ill pregnant patients may outweigh the potential risks. Obviously, careful monitoring of hemodynamic parameters in both the mother and fetus are a priority. Some authors advocate emergent cesarean delivery, if near term, prior to attempting surgical management of vascular malformations.[29] However, studies have suggested that surgical management of ruptured aneurysms during pregnancy is associated with significantly lower maternal and fetal mortality.[9] This did not hold true for surgical excision of arteriovenous malformations, despite a high risk of rebleeding (up to 30%) within the same pregnancy.[9,19] Since AVMs are now frequently repaired endovascularly, benefits may still outweigh the risks. Studies have suggested that route of delivery, cesarean versus vaginal, does not affect outcome in patients with a vascular anomaly.[18]

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