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Stroke in Pregnancy

Stroke in Pregnancy: Consensus Statements by the Canadian Stroke Best Practices Stroke in Pregnancy Writing Group.

Introduction:

Stroke, the sudden loss of neurological function due to neuronal injury of a vascular cause, is a leading cause of disability in adults. When stroke occurs during pregnancy, the impact on the mother, child and families can be devastating. A recent systematic review and meta-analysis funded by Heart & Stroke showed that stroke affects 30/100,000 pregnancies, roughly 3 times higher than the risk in young adults. Several aspects of pregnancy can increase the risk of stroke including: hypertensive disorders of pregnancy (gestational hypertension, preeclampsia with or without chronic hypertension, eclampsia, HELLP syndrome [hemolysis, elevated liver enzymes and low platelets syndrome]) and their complications: hematologic and prothrombotic changes, particularly in the third trimester and post-partum periods; hyperemesis resulting in hemoconcentration; and changes to cerebral vasculature (for example, reversible cerebral vasoconstriction syndrome (RCVS), as well as growth of existing arteriovenous malformations).

Given this etiological variability, the practical limitations to clinical research in pregnant patients with stroke, and the rarity of events, it is not surprising that there is limited literature to guide important management decisions. Yet, stroke is sufficiently common that most specialists providing either obstetrical or stroke care encounter either women with a past stroke wanting to get pregnant, or women who develop a stroke during or just after a pregnancy. Thus, there is a need for a rational approach to management decisions, based on the best available literature and guided by expert consensus.

Goal: To provide guidance on the management of stroke in pregnancy based on a critical appraisal of current evidence on obstetrical and stroke management informed by expert review and appraisal.

Scope: A set of two consensus statements have been developed based on the process above, focused on the unique aspects of pregnancy-related stroke. Part One addresses secondary prevention for women who have a history of stroke and are pregnant or planning to become pregnant; Part Two addresses treatment and management of a woman who experiences a stroke while pregnant or in the early postpartum period.

Most consensus statements within these documents are applicable to both ischemic and hemorrhagic stroke. In cases where the statements are applicable to one type or the other, these will be explicitly stated.

This set of consensus statements seeks to organize an approach and apply existing evidence to this specific subset of stroke patients (those pregnant) and this specific subset of pregnant patients (those with acute or previous stroke).

Target audience for this consensus statement is health care professionals that manage stroke and/or pregnancy, including maternal-fetal medicine specialists, obstetricians, family physicians, obstetrical medicine specialists, obstetrical anesthetists, internists, neurologists and critical care specialists, emergency medicine, radiologists, nursing professionals from neurological, obstetrical and critical care backgrounds, and stroke rehabilitation specialists 

Part One: Prevention of Recurrent Stroke in Pregnant Women and Women Planning a Pregnancy

Prevention of Stroke in Pregnancy – 2017

This consensus statement is focused on the issues of stroke prevention encountered by a woman who has had a stroke in the past and is now planning to become pregnant, is currently pregnant, or who has had a stroke in pregnancy but is beyond the hyperacute phase. We first address general management considerations from preconception counseling to pregnancy and post-partum including breastfeeding (Part 1). We then review management considerations for commonly used secondary prevention strategies (Part 2), including antithrombotic medications (both antiplatelets and anticoagulants), blood pressure management, lipid management and diabetes care. Finally, we address some of the more common specific causes of stroke that affect young women of childbearing age and pregnancy (Part 3) including cardioembolic stroke, cerebral venous sinus thrombosis and cerebral artery dissection.

Prevention and Pregnancy Consensus Statement 2017 module contents

Publication of the Secondary Prevention of Stroke during Pregnancy Consensus statement

in the International Journal of Stroke

Citing the Secondary Prevention of Stroke during Pregnancy 2017 Module

Richard H Swartz (Co-First Author), Noor Niyar N. Ladhani (Co-First Author),  Norine Foley, Kara Nerenberg, Simerpreet Bal, Jon Barrett, Cheryl Bushnell, Wee-Shian Chan,  Radha Chari, Dariush Dowlatshahi, Meryem El Amrani, Shital Gandhi, Gord Gubitz, Michael D Hill, Andra James, Thomas Jeerakathil, Albert Jin, Adam Kirton, Sylvain Lanthier,  Andrea Lausman, Lisa Rae Leffert  Jennifer  Mandzia,  Bijoy Menon, Aleksandra Pikula, Alexandre Poppe, Jayson Potts, Joel Ray, Gustavo Saposnik, Mukul Sharma, Eric E Smith, Sanjit Bhogal, Elisabeth Smitko, and M Patrice Lindsay (Senior and Corresponding Author),  on behalf of the Heart and Stroke Foundation Canadian Stroke Best Practice Advisory Committees. In Lindsay MP, Gubitz G, Dowlatshahi D, Harrison E, and Smith EE (Editors).  Canadian Stroke Best Practice Recommendations 6th Edition: Secondary Stroke prevention during Pregnancy Consensus Statement, 2017; Ottawa, Ontario Canada: Heart and Stroke Foundation. www.strokebestpractices.ca

Stroke Foundation’s Stroke Team at strokebestpractices@heartandstroke.ca.

Part Two: Acute Stroke Management during Pregnancy

Acute Stroke Management during Pregnancy Participants

This consensus statement is focused on the issues of acute stroke management for a woman who experiences an acute stroke during pregnancy or in the postpartum period (generally including the first 12 weeks post delivery).  It starts with the onset of stroke symptoms, followed by assessment, diagnosis and clinical decision-making regarding emergent treatments for these women. Stroke is a time-sensitive emergency condition. Once the patient is medically stable, the acute goals shift to ongoing management of stroke sequelae and rehabilitation requirements that meet the goals of the patient (Swartz et al 2017).

When a stroke occurs in pregnancy, a standardized approach to coordinated emergent care is essential for investigation, diagnosis, and intervention planning with the goal of maximizing maternal and fetal wellbeing. In pregnancy, care requires careful consideration of the potential impacts of a stroke on the mother’s health and survival, the fetus’ health and survival, multiple competing etiologies, and the need for interdisciplinary perspectives, all while time is of the essence. Typical decision-making related to the non-pregnant patient must be nuanced by the timing of stroke within the pregnancy, stroke severity, expected maternal outcomes, and the known or theoretical impact of decisions and interventions on the fetus. Whenever possible, the same decisions for acute treatment and management outside of pregnancy should be considered for a woman who is pregnant. In these cases, maternal health is prioritized and delays or deferral of critical steps in diagnosis and life-saving care due to pregnancy should be minimized.

Acute Stroke Management during Pregnancy Module Contents

Canadian Stroke Best Practice Consensus Statement: Acute Stroke Management during Pregnancy in the International Journal of Stroke

Publication of the Secondary Prevention of Stroke during Pregnancy Consensus statement International Journal of Stroke:

Citing the Management of Acute Stroke during Pregnancy during Pregnancy 2018 Module

Noor Niyar N. Ladhani (Co-First Author) ,  Richard H Swartz (Co-First Author) , Norine Foley, Kara Nerenberg , Eric E Smith, Gord Gubitz, Dariush Dowlatshahi, Jayson Potts, Joel G Ray, Jon Barrett, Cheryl Bushnell, Simerpreet Bal, Wee-Shian Chan,  Radha Chari, Meryem El Amrani, Shital Gandhi, Michael D Hill, Andra James , Thomas Jeerakathil, Albert Jin, Adam Kirton , Sylvain Lanthier ,  Andrea Lausman , Lisa Rae Leffert,   Jennifer  Mandzia, Bijoy Menon, Aleksandra Pikula , Alexandre Poppe, Gustavo Saposnik, Mukul Sharma, Sanjit Bhogal, Elisabeth Smitko, and M Patrice Lindsay (Senior and Corresponding Author),  on behalf of the Heart and Stroke Foundation Canadian Stroke Best Practice and Quality Advisory Committees; in collaboration with the Canadian Stroke Consortium. In Lindsay MP, Gubitz G, Dowlatshahi D, Harrison E, and Smith EE (Editors).  Canadian Stroke Best Practice Recommendations 6th Edition: Acute Stroke Management during Pregnancy Consensus Statement, 2018; Ottawa, Ontario Canada: Heart and Stroke Foundation.  www.strokebestpractices.ca

Comments

We invite comments, suggestions, and inquiries on the development and application of the Canadian Stroke Best Practice Recommendations.  Please forward comments to the Heart and Stroke Foundation’s Stroke Team at strokebestpractices@heartandstroke.ca.