Bonveda's Blog

Pregnancy and the puerperium represent a special risk for stroke because of the procoagulant state. It was once thought that these strokes were usually venous, but recent
data have shown that strokes in pregnancy and the first week postpartum are arterial. Venous infarction occurs in the succeeding month. The incidence of strokes is about 10 times greater during pregnancy and the puerperium. Equal numbers occur during pregnancy and the puerperium. A careful workup is necessary, and anticoagulation is given when appropriate. Warfarin crosses the placenta, so heparin is usually used. Care must be taken not to induce thrombocytopenia. The anticardiolipin antibody syndrome is associated with increased spontaneous abortion, but patients have carried to term with steroids and aspirin. These strokes are usually in the carotid territory. The low level anticardiolipin elevations seen in elderly pantients with stroke probably do not require therapy.
venous thrombosis may be suspected when the patient presents with headache, seizures, and obtundation later in the puerperium. Specific syndromes may point to specific dural venous sinuses. Cranial nerves III,IV,V,and VI suggest the cavernous sinus, aphasia the lateral sinus, and leg weakness the sagittal sinus. Although these lesions often are quite hemorrhagic, heparin therapy seems to be helpful.
vascular lesions may grow during pregnancy. When a patient experiences subarachnoid hemorrhage during pregnancy, the abdomen should be shielded and prompt angiography performed. The risk for bleeding appears greatest during the second trimester, but rupture may occur during parturition. If the lesion cannot be readily managed, careful vaginal delivery can be allowed if the Valsalva maneuver can be avoided; Valsalva increases the venous pressure and the likelihood of rupture. Cesarean section may be needed to protect the mother. The risk drops after delivery but is still high enough to warrant prophylactic surgery, if feasible.
The risk for aneurismal bleeding increases with each month of pregnancy. Aneurysmal bleeding is likely to recur severely and soon. Labor may be triggered by aneurismal rupture. The risk for rebleeding during vaginal delivery is not prohibitive if the patient is multiparous or in good control. If the patient is late in pregnancy, delivery and aneurismal surgery should be undertaken. If the patient is early in pregnancy, the aneurysm must be managed.
Stroke in pregnancy may create problems for the mother’s ability to care for her offspring. The problem of subarachnoid hemorrhage is highly complex even without pregnancy , and a careful multispecialty effort is critical to a successful outcome. The death rate of patients treated conservatively is in the range of 60% to 70% , and delay should be avoided. The increased risk for stroke with oral contraceptives seems to be associated with factors such as hypertension and smoking.