Canadian Stroke Best Practice Consensus Statement: Acute Stroke Management during pregnancy

Abstract

The Canadian Stroke Best Practice Consensus Statement Acute Stroke Management during Pregnancy is the second of a two-part series devoted to stroke in pregnancy. The first part focused on the unique aspects of secondary stroke prevention in a woman with a prior history of stroke who is, or is planning to become, pregnant. This document focuses on the management of a woman who experiences an acute stroke during pregnancy. This consensus statement was developed in recognition of the need for a specifically tailored approach to the management of this group of patients in the absence of any broad-based, stroke-specific guidelines or consensus statements, which do not exist currently. The foundation for the development of this document was the concept that maternal health is vital for fetal well-being; therefore, management decisions should be based first on the confluence of two clinical considerations: (a) decisions that would be made if the patient wasn't pregnant and (b) decisions that would be made if the patient hadn't had a stroke, then nuanced as needed. While empirical research in this area is limited, this consensus document is based on the best available literature and guided by expert consensus. Issues addressed in this document include initial emergency management, diagnostic imaging, acute stroke treatment, the management of hemorrhagic stroke, anesthetic management, post stroke management for women with a stroke in pregnancy, intrapartum considerations, and postpartum management. These statements are appropriate for healthcare professionals across all disciplines and system planners to ensure pregnant women who experience a stroke have timely access to both expert neurological and obstetric care.

Postpartum Ischemic Stroke: A Rare Case

“…Timely assessment and management of postpartum stroke are of paramount importance as it carries a mortality rate of 2%-10% [ 9 ]. The management of postpartum stroke is challenging because of pregnancy being an exclusion criterion for reperfusion therapy.…”

“…The management of postpartum stroke is challenging because of pregnancy being an exclusion criterion for reperfusion therapy. Although intravenous thrombolysis has shown to reduce morbidity in non-pregnant women, its safety and efficacy in the early postpartum period are not well established [ 9 ]. The use of thrombolytics, as suggested by Akazawa and Nishida, was associated with a high risk of bleeding after the cesarean section in comparison with vaginal deliveries; thus, its use was worth avoiding [ 10 ].…”

Ontario Neurodegenerative Disease Research Initiative (ONDRI): Structural MRI Methods and Outcome Measures

“…In Canada, ~62,000 people are treated for stroke and transient ischemic attack. In a series of publications, the Heart and Stroke Foundation Canadian Best Practice Committees have been developing various evidence-based recommendations to address issues regarding: telestroke technologies ( 95 ); managing transitions of care following stroke ( 96 ); mood, cognition, and fatigue following stroke ( 97 ); hyperacute stroke care ( 98 ); secondary prevention of stroke ( 99 ); and stroke during pregnancy ( 100 , 101 ).…”

Neurovascular disorders in pregnancy: A review

“…In pregnancy, low-dose aspirin is recommended secondary prevention, as there is insufficient data to support anticoagulation without an obvious stroke source. 15 Investigation of stroke etiology in pregnancy includes MRI without contrast, electrocardiogram, cardiac telemetry, transthoracic echocardiogram with bubble study to evaluate for shunt, carotid ultrasound, transcranial dopplers, medical risk factor stratification (including HbA1c, lipid panel, smoking history), and thrombophilia workup. 6 CVST and venous stroke CVST refers to thrombus formation in the veins or venous sinuses of the head.…”