Abstract:Stroke during pregnancy is rare, but after occurring, most patients develop serious neurological conditions. Hemorrhagic stroke, including intracerebral hemorrhage and subarachnoid hemorrhage, often requires emergency surgical intervention. In addition to significant maternal physiological changes, the potential for fetal harm should be considered during anesthetic management of these patients. Whether cesarean section or neurosurgical intervention should be prioritized or performed simultaneously in pregnant … Show more
“…management of hypotension, use of osmotic diuretics, and mechanical hyperventilation) may pose a risk to the fetus. 53 7.0 Poststroke antenatal obstetric considerations for women with a stroke in pregnancy i. Where possible, obstetric care should be managed with access to, or in collaboration with, stroke care.…”
Section: Poststroke Antenatal Obstetric Considerations For Women Withmentioning
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.
“…management of hypotension, use of osmotic diuretics, and mechanical hyperventilation) may pose a risk to the fetus. 53 7.0 Poststroke antenatal obstetric considerations for women with a stroke in pregnancy i. Where possible, obstetric care should be managed with access to, or in collaboration with, stroke care.…”
Section: Poststroke Antenatal Obstetric Considerations For Women Withmentioning
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.
“…Medical management of ICH typically does not require delivery in preterm fetuses. 16 It has been suggested that focus should be placed on maternal health for <26 to 28 weeks gestation, 32 with delivery via cesarean delivery for > 34 weeks gestation. 34 In general, cesarean delivery should be reserved for obstetric indications.…”
Section: Antepartum and Intrapartum Considerationsmentioning
confidence: 99%
“…A concurrent cesarean delivery may be considered if the fetus is viable. It has been suggested that if the gestational age is >28 to 32 weeks, cesarean delivery before craniotomy may improve fetal outcomes, given the fetal risk of neurosurgery 32. Fetal status should be optimized as much as possible before and during surgery, which may include continuous maternal cardiac monitoring, replacement of blood and clotting factors, avoiding drugs that may induce uterine relaxation or fetal depression, and positioning in the left lateral supine position if allowed by the neurosurgeon 1…”
Hemorrhagic stroke carries a high risk of disability and mortality. The obstetrical population is at increased risk. Prompt diagnosis and maternal stabilization with a multidisciplinary approach are the mainstays in management. Computed tomography head is the diagnostic imaging of choice and is considered safe in pregnancy. Fetal status optimization before neurosurgery and delivery should be considered if the fetus is viable or if worsening maternal condition. Obstetric indications guide the mode of delivery. Cesarean delivery may be indicated to reduce increasing intracranial pressure. Neuraxial anesthesia should be considered to minimize catecholamine surges, reduce sedation, and control blood pressures.
“…Pregnant stroke patients, such as nonpregnant patients, have better outcomes when cared for at a specialized stroke center, and therefore, stabilization and emergent transfer may be indicated 62 . During the acute intervention, continuous electronic fetal monitoring may be performed to assess fetal well-being 84 . Consideration for maternal stability, gestational age, and the willingness to deliver if nonreassuring fetal status is identified should be addressed in a multidisciplinary fashion 85,86 .…”
Section: Managementmentioning
confidence: 99%
“…62 During the acute intervention, continuous electronic fetal monitoring may be performed to assess fetal well-being. 84 Consideration for maternal stability, gestational age, and the willingness to deliver if nonreassuring fetal status is identified should be addressed in a multidisciplinary fashion. 85,86 After intervention, the pregnancy can be allowed to progress to term if the maternal condition is favorable and stable.…”
ImportanceThe maternal risk of strokes in the United States is approximately 30/100,000 pregnancies, and strokes are the eighth leading cause of maternal death. Because of the relationship between stroke and significant neurological disability/maternal death, obstetrical health care providers must be able to identify, evaluate, diagnosis, and treat these women.Evidence AcquisitionPubMed was searched using the search terms “stroke” OR “cerebrovascular accident” OR “intracranial hemorrhage” AND “pregnancy complications” OR “risk factors” OR “management” OR “outcome.” The search was limited to the English language and was restricted to articles from 2000 to 2020.ResultsThere were 319 abstracts identified, and 90 of the articles were ultimately used as the basis of this review. Presenting stroke signs and symptoms include headache, composite neurologic defects, seizures, and/or visual changes. Diagnosis is typically made with computed tomography scan using abdominal shielding or magnetic resonance imaging without contrast. Management options for an ischemic stroke include reperfusion therapy with intravenous recombinant tissue plasminogen activator catheter-based thrombolysis and/or mechanical thrombectomy. Hemorrhagic strokes are treated similarly to strokes outside of pregnancy, and that treatment is based on the severity and location of the hemorrhage.Conclusions and RelevanceEarly recognition and management are integral in decreasing the morbidity and mortality associated with a stroke in pregnancy.Relevance StatementThis study was an evidence-based review of stroke in pregnancy and how to diagnose and mange a pregnancy complicated by a stroke.Target AudienceObstetricians and gynecologist, family physiciansLearning ObjectivesAfter completing this learning activity, the participant should be better able to identify the pregnancy-related risk factors for a stroke; explain the presenting signs and symptoms of a stroke in pregnancy; describe the imaging modalities available to diagnose a stroke; and outline treatment options for an ischemic stroke and a hemorrhagic stroke.
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