Cerebrovascular disorders complicating pregnancy--beyond eclampsia

In-hospital outcomes and recurrence of stroke during pregnancy and puerperium

BACKGROUND

There are limited data regarding the best management and outcomes of acute stroke during pregnancy and the puerperium.

METHODS

Pregnancy-related hospitalizations with age > 18 years were identified from the Nationwide Readmissions Database 2016-2018. The study cohort consisted of all patients with acute stroke and a 5% random sample of the remaining non-stroke hospitalizations. Logistic regression and survival analyses were used to compare the in-hospital outcomes and readmissions in patients with and without acute stroke.

RESULTS

There were 11,829,044 pregnancy-related hospitalizations, of which 4057 had acute stroke. The mean ± SD age of the study cohort was 29.0 ± 5.7 years. Among patients with acute ischemic stroke, 60 (3.7%) patients received intravenous thrombolysis and 112 (6.8%) patients underwent endovascular thrombectomy. Among patients with intracranial hemorrhage, 205 (10.5%) patients underwent ventriculostomy and 18 (0.9%) patients underwent decompressive craniotomy. Patients with stroke had longer length of stay (mean: 10.7 vs 2.7 days), higher in-hospital mortality (4.6% vs 0.0001%) and were less likely to discharge home (73.0% vs 98.6%). Non-elective readmission within 90 days of discharge occurred in 14.8% of patients with stroke versus in 3.9% of patients without stroke. Readmissions due to cerebrovascular events occurred in 2.3% of patients with stroke versus in 0.007% of patients without stroke within 1 year of discharge, with mean ± SD time to readmission 66.2 ± 78.0 days.

CONCLUSION

Stroke is a serious complication of pregnancy, associated with high morbidity and mortality. Recurrence of stroke occurs in a small proportion of patients, and the risk is highest during the initial 3 months.

Guidelines for the management of women with severe pre-eclampsia

OBJECTIVE

To provide national guidelines for the management of women with severe pre-eclampsia.

DESIGN

A consensus committee of 26 experts was formed. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised.

METHODS

The last SFAR and CNGOF guidelines on the management of women with severe pre-eclampsia were published in 2009. The literature is now sufficient for an update. The aim of this expert panel guidelines is to evaluate the impact of different aspects of the management of women with severe preeclampsia on maternal and neonatal morbidities separately. The experts studied questions within 7 domains. Each question was formulated according to the PICO (Patients Intervention Comparison Outcome) model and the evidence profiles were produced. An extensive literature review and recommendations were carried out and analysed according to the GRADE® methodology.

RESULTS

The SFAR/CNGOF experts panel provided 25 recommendations: 8 have a high level of evidence (GRADE 1+/-), 9 have a moderate level of evidence (GRADE 2+/-), and for 7 recommendations, the GRADE method could not be applied, resulting in expert opinions. No recommendation was provided for 3 questions. After one scoring round, strong agreement was reached between the experts for all the recommendations.

CONCLUSIONS

There was strong agreement among experts who made 25 recommendations to improve practices for the management of women with severe pre-eclampsia.

Postpartum Cerebral Venous Thrombosis-A Single-Center Experience

Background: Cerebral venous thrombosis (CVT) is a rare variant of stroke in the general population, but an important subtype among pregnancy- and puerperium-related cases. Studies describing its risk factors and clinical characteristics are limited. The aim of our study is to disclose these aspects and compare with cases unrelated to pregnancy and puerperium. Materials and Methods: We performed a retrospective analysis including 88 consecutive cases from a tertiary neurology clinic with a diagnosis of CVT. Ten of the 88 cases (11.3%) appeared during the postpartum period. Results: The mean age of the puerperal CVT cases was 26.5 years. The main pregnancy-related risk factors besides puerperium were cesarean delivery (5/10), preeclampsia (2/10), and stillbirth (1/10). General risk factors for thrombosis, i.e., infection, smoking, and primary hypercoagulability, were identified in 50% of cases. Onset was in the first 3 weeks after delivery, with a mean value of 9.6 ± 5.6 days. Headache was present in 90% of postpartum CVT cases and in 76.1% of non-postpartum female cases. Seizures were more frequent in the postpartum group (60% vs. 34.8%). Onset was acute (<48 h) in 50% of postpartum cases and in 30.4% of the non-postpartum female group. The Rankin score at discharge was significantly lower in the postpartum group (0.22 vs. 0.7, p = 0.02), suggesting a more favorable short-term outcome. Conclusions: The early postpartum period represents an important risk for the development of CVT. Cesarean delivery and preeclampsia, besides general risk factors such as infection, smoking, and primary thrombophilia, contribute to enhanced risk. Puerperium-related CVT presents a more favorable outcome compared with CVT with other etiologies.

Ischemic stroke and cerebral venous sinus thrombosis in pregnancy

Maternal ischemic stroke and cerebral venous sinus thrombosis (CVST) are dreaded complications of pregnancy and major contributors to maternal disability and mortality. This chapter summarizes the incidence and risk factors for maternal arterial ischemic stroke (AIS) and CVST and discusses the pathophysiology of maternal AIS and CVST. The diagnosis, treatment, and secondary preventive strategies for maternal stroke are also reviewed. Special populations at high risk of maternal stroke, including women with moyamoya disease, sickle cell disease, HIV, thrombophilia, and genetic cerebrovascular disorders, are highlighted.

ACOG Practice Bulletin No. 202: Gestational Hypertension and Preeclampsia

Hypertensive disorders of pregnancy constitute one of the leading causes of maternal and perinatal mortality worldwide. It has been estimated that preeclampsia complicates 2-8% of pregnancies globally (). In Latin America and the Caribbean, hypertensive disorders are responsible for almost 26% of maternal deaths, whereas in Africa and Asia they contribute to 9% of deaths. Although maternal mortality is much lower in high-income countries than in developing countries, 16% of maternal deaths can be attributed to hypertensive disorders (). In the United States, the rate of preeclampsia increased by 25% between 1987 and 2004 (). Moreover, in comparison with women giving birth in 1980, those giving birth in 2003 were at 6.7-fold increased risk of severe preeclampsia (). This complication is costly: one study reported that in 2012 in the United States, the estimated cost of preeclampsia within the first 12 months of delivery was $2.18 billion ($1.03 billion for women and $1.15 billion for infants), which was disproportionately borne by premature births (). This Practice Bulletin will provide guidelines for the diagnosis and management of gestational hypertension and preeclampsia.

Stroke during pregnancy and puerperium among Japanese women: a single-center registry

BACKGROUND

Stroke is one of the major causes of maternal death. This study aimed to analyze the maternal and fetal outcomes of stroke occurred during pregnancy and puerperium.

METHODS

We conducted a retrospective analysis of patients admitted to our perinatology center between 1982 and 2012 with a diagnosis of acute cerebral stroke during pregnancy or within 6 weeks postpartum.

RESULTS

Thirty-four patients were registered and all the patients had never been diagnosed as stroke nor detected cerebrovascular abnormalities before the current pregnancies. They were divided into 8 ischemic strokes (ISs) and 26 intracranial hemorrhage group. In the hemorrhage group, there was a spontaneous abortion and two patients chose artificial abortions to avoid rehemorrhage, and there were another three intrauterine fetal deaths (IUFDs) in the acute stage of maternal stroke. More patients in hemorrhage group delivered in preterm than in IS group for the treatment of stroke, 10/23 (43%) versus 0/8 (0%), p < .05. More patients in hemorrhage group had low Glasgow Coma Scale (GCS) (3-8) than in IS group at the onset of the stroke, 12/26 (46%) versus 0/8 (0%), p < .05. There were three maternal deaths and 6/23 (26%) were neurologically dependent in hemorrhage group in the chronic stage, whereas 87% were independent in IS group, p < .05.

CONCLUSIONS

Hemorrhagic stroke was more common etiology of stroke related to pregnancy than IS in this study. Intensive and multidisciplinary care was needed especially in hemorrhagic stroke related to pregnancy as in the hemorrhagic stroke the fetal survival rate was lower, and maternal conscious levels at the onset of the stroke and neurological outcomes in the chronic stage were worse than IS.

Clinical and imaging profile of patients with new-onset seizures & a presumptive diagnosis of eclampsia - A prospective observational study

OBJECTIVE

To study the clinical and imaging profile of patients with new-onset seizures with a presumptive diagnosis of eclampsia.

METHODS

This was a cross-sectional study, conducted in a tertiary teaching hospital, on pregnant women presenting with new onset seizures with presumptive diagnosis of eclampsia excluding those with pre-existing neurological conditions. Demographic details, medical and obstetric examination findings were noted. All women underwent neuroimaging within 5 days of onset seizures.

RESULTS

Presumptive diagnosis of eclampsia was made in 0.7% (n = 186) of women delivering during the time period. Most women (55.4%) presented with seizures in the antenatal period. Neuroimaging is performed in 130 cases and it was found to be abnormal in 45.4% of women (59/130). Most common associated neurological condition was Posterior Reversible Encephalopathy Syndrome in 20% (n = 26) followed by Cerebral Venosus Sinus Thrombosis in 10% (n = 14). All six women with primary intracerebral haemorrhage succumbed to the disease.

CONCLUSION

New-onset seizures may be the initial presentation of uncommon and unpredictable complication of pregnancy with serious maternal/ fetal morbidity and mortality. Neuroimaging will help in these patients to avoid the delay or misdiagnosis, resulting in early initiation of specific treatment which will help to improve and optimize outcomes.

The incidence of pregnancy-related stroke: A systematic review and meta-analysis

Background

Stroke risk is increased during pregnancy, but estimates of pregnancy-related stroke incidence vary widely.

Aims

A systematic review and meta-analysis was conducted to assess the incidence of stroke during pregnancy and the puerperium. Ovid Medline, EMBASE, and ISI Web of Science were searched for studies published between 1990 and January 2017 reporting stroke incidence during pregnancy and postpartum, from defined pregnancy populations. Pooled analyses were conducted using a random effects approach and expressed as an incidence rate per 100,000 pregnancies, with 95% confidence intervals. Subgroup analyses of stroke type and timing were conducted.

Summary of review

Eleven studies met inclusion criteria. Variation in estimated rates was noted based on geography and study methodology. The pooled crude rate of pregnancy-related stroke was 30.0 per 100,000 pregnancies (95% confidence interval 18.8–47.9). The pooled crude rates from nonhemorrhagic stroke (arterial and cerebral venous sinus thrombosis) were 19.9 (95% confidence interval 10.7–36.9) and from hemorrhage 12.2 (95% confidence interval 6.4–23.2) per 100,000 pregnancies. For studies separately reporting cerebral venous sinus thrombosis, the rates were roughly equal between ischemic stroke (12.2, 95% confidence interval 6.7–22.2), cerebral venous sinus thrombosis (9.1, 95% confidence interval 4.3–18.9), and hemorrhage (12.2, 95% confidence interval 6.4–23.2). The crude stroke rate for antenatal/perinatal stroke was 18.3 (95% confidence interval 11.9–28.2), and for postpartum stroke was 14.7 (95% confidence interval 8.3–26.1).

Conclusions

Stroke affects 30.0 per 100,000 pregnancies, with ischemia, cerebral venous sinus thrombosis, and hemorrhage causing roughly equal numbers and with highest risk peripartum and postpartum. Organized approaches to the management of this high-risk population, informed by existing evidence from stroke and obstetrical care are needed.

Inherited and Uncommon Causes of Stroke

PURPOSE OF REVIEW

This article is a practical guide to identifying uncommon causes of stroke and offers guidance for evaluation and management, even when large controlled trials are lacking in these rarer forms of stroke.

RECENT FINDINGS

Fabry disease causes early-onset stroke, particularly of the vertebrobasilar system; enzyme replacement therapy should be considered in affected patients. Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), often misdiagnosed as multiple sclerosis, causes migraines, early-onset lacunar strokes, and dementia. Moyamoya disease can cause either ischemic or hemorrhagic stroke; revascularization is recommended in some patients. Cerebral amyloid angiopathy causes both microhemorrhages and macrohemorrhages, resulting in typical stroke symptoms and progressive dementia. Pregnancy raises the risk of both ischemic and hemorrhagic stroke, particularly in women with preeclampsia/eclampsia. Pregnant women are also at risk for posterior reversible encephalopathy syndrome (PRES), reversible cerebral vasoconstriction syndrome, and cerebral venous sinus thrombosis. Experts recommend that pregnant women with acute ischemic stroke not be systematically denied the potential benefits of IV recombinant tissue plasminogen activator.

SUMMARY

Neurologists should become familiar with these uncommon causes of stroke to provide future risk assessment and family counseling and to implement appropriate treatment plans to prevent recurrence.

Neurologic complications in critically ill pregnant patients

Neurologic complications in a critically ill pregnant woman are uncommon but some of the complications (such as eclampsia) are unique to pregnancy and the puerperal period. Other neurologic complications (such as seizures in the setting of epilepsy) may worsen during pregnancy. Clinical signs and symptoms such as seizure, headache, weakness, focal neurologic deficits, and decreased level of consciousness require careful consideration of potential causes to ensure prompt treatment measures are instituted to prevent ongoing neurologic injury. Clinicians should be familiar with syndromes such as pre-eclampsia, eclampsia, stroke, posterior reversible encephalopathy syndrome, and reversible cerebral vasoconstriction syndrome. Necessary imaging studies can usually be performed safely in pregnancy. Scoring systems for predicting maternal mortality are inadequate, as are recommendations for neurorehabilitation. Tensions can arise when there is conflict between the interests of the mother and the interests of the fetus, but in general maternal health is prioritized. The complexity of care requires a multidisciplinary and multiprofessional approach to achieve best outcome in an often unexpected situation.

Strokes Associated With Pregnancy and Puerperium: A Nationwide Study by the Japan Stroke Society

BACKGROUND AND PURPOSE

The incidence and cause of strokes associated with pregnancy and the puerperium are still not fully understood. The aim of this study was to characterize pregnancy-related strokes in Japan using a large-scale survey with current imaging techniques.

METHODS

A retrospective analysis was conducted based on clinical chart reviews in 736 stroke teaching hospitals certified by the Japan Stroke Society between 2012 and 2013, using a web-based questionnaire requesting the detailed clinical course without any personally identifying information. The collection rate of this questionnaire was 70.5%, with 151 pregnancy-associated strokes extracted.

RESULTS

Hemorrhagic strokes were observed in 111 cases (73.5%), ischemic strokes in 37 (24.5%), and mixed type in 3 cases (2.0%). The estimated incidence of pregnancy-associated stroke was 10.2 per 100 000 deliveries. Major causes of hemorrhage were aneurysm (19.8%), arteriovenous malformation (17.1%), pregnancy-induced hypertension (11.7%), and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) (8.1%). Preexisting cerebrovascular diseases responsible for hemorrhage were detected in 59 cases (53.1%). Among the ischemic strokes, 28 (75.7%) were arterial and 9 (24.3%) were venous infarctions. The most frequent cause of arterial infarctions was reversible cerebral vasoconstriction syndrome. Hemorrhagic stroke showed much poorer prognosis than ischemic stroke.

CONCLUSIONS

The incidence of pregnancy-associated stroke in Japan did not seem higher than that in other Asian and Western countries. The proportion of hemorrhagic stroke among Japanese women was much higher than that in white women. Preexisting cerebrovascular diseases and reversible cerebral vasoconstriction syndrome play a key role in hemorrhagic and ischemic stroke, respectively.

The risk factors for labor onset hypertension

Our aim was to clarify the perinatal outcomes of and risk factors for hypertension that is first detected after labor onset (labor onset hypertension, LOH), which may be a risk factor for eclampsia and stroke during labor. A total of 1349 parturient women who did not exhibit preeclampsia or gestational hypertension prior to labor were examined. The patients were classified into four groups: the normotensive (n=1023) (whose systolic blood pressure (SBP) remained below 140 mm Hg throughout labor), mild LOH (n=241) (whose maximum SBP during labor ranged from 140 to 159 mm Hg), severe LOH (n=66) (whose maximum SBP during labor ranged from 160 to 179 mm Hg) and emergent LOH groups (n=19) (whose maximum SBP during labor was greater than 180 mm Hg). The perinatal outcomes and patient characteristics of the four groups were compared. Twenty-four percent of the pregnant women who remained normotensive throughout pregnancy developed hypertension during labor. One of the patients in the emergent LOH group developed eclampsia. The blood pressure at delivery and frequencies of hypotensor use, interventional delivery and low Apgar scores differed significantly among the four groups. The following risk factors for severe/emergent LOH were extracted: being over 35 years old, a body mass index at delivery of >30, an SBP at 36 weeks' gestation of 130-134 mm Hg, an SBP at admission of 130-139 mm Hg, proteinuria (a score of 2+ on the dipstick test) and severe edema. The risk factors for severe/emergent LOH were identified in this study. In high risk cases, repeatedly measuring maternal blood pressure during delivery might help detect critical hypertension early.

Hypertensive Emergencies in Pregnancy

The prevalence of hypertensive disorders in pregnancy is increasing. The etiology and pathophysiology of hypertensive disorders in pregnancy remain poorly understood. Hypertensive disorders are a major cause of maternal and perinatal morbidity and mortality. Treatment of hypertension decreases the incidence of severe hypertension, but it does not impact rates of preeclampsia or other pregnancy complications. Several antihypertensive medications are commonly used in pregnancy, although there is a lack of randomized controlled trials. Severe hypertension should be treated immediately to prevent maternal end-organ damage. Appropriate antepartum, intrapartum, and postpartum management is important in caring for patients with hypertensive disorders.

Acute cerebrovascular disease occurring after hospital discharge for labor and delivery

BACKGROUND AND PURPOSE

The risk of stroke and other postpartum cerebrovascular disease (CVD) occurring after hospital discharge for labor and delivery is uncertain.

METHODS

We performed a retrospective cohort study using administrative databases to identify all pregnant women who were hospitalized for labor and delivery at nonfederal, acute care hospitals in California from 2005 to 2011 and who were discharged without an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of CVD. The primary outcome was an acute CVD composite defined as any ischemic stroke, intracranial hemorrhage, cerebral venous sinus thrombosis, pituitary apoplexy, carotid/vertebral artery dissection, hypertensive encephalopathy, or other acute CVD occurring after hospital discharge and before 6 weeks after labor and delivery. Descriptive statistics were used to estimate the incidence of postdischarge CVD. Multivariate logistic regression was used to evaluate the association between selected baseline factors and postdischarge CVD.

RESULTS

The rate of any postdischarge acute CVD was 14.8 per 100 000 patients (95% confidence interval [CI], 13.2-16.5). Risk factors for any acute CVD were eclampsia (odds ratio [OR], 10.1; 95% CI, 3.09-32.8), chronic kidney disease (OR, 5.4; 95% CI, 2.5-11.8), black race (OR, 2.5; 95% CI, 1.9-3.3), preeclampsia (OR, 2.1; 95% CI, 1.6-2.8), pregnancy-related hematologic disorders (OR, 1.8; 95% CI, 1.3-2.5), and age (OR, 1.5 per decade; 95% CI, 1.3-1.8).

CONCLUSIONS

The incidence of postpartum acute CVD after hospital discharge for labor and delivery is similar to rates reported for all postpartum events in previous publications, suggesting that a substantial proportion of postpartum CVD occurs after discharge.

Cerebrovascular disorders complicating pregnancy

PURPOSE OF REVIEW

This article discusses the physiologic changes of pregnancy and how they affect risk of ischemic and hemorrhagic stroke and then reviews epidemiology, diagnosis, and treatment of ischemic and hemorrhagic stroke in pregnancy and the puerperium.

RECENT FINDINGS

This article updates our understanding of the relationship of preeclampsia/eclampsia to the posterior reversible encephalopathy syndrome and the reversible cerebral vasoconstriction syndrome, emphasizing their shared pathogenesis. It reviews the most recent data and offers recommendations concerning the use of thrombolytic and other revascularization therapies for pregnancy-related strokes.

SUMMARY

Although cerebrovascular complications are uncommon occurrences during pregnancy and the puerperium, stroke is still the most common seriously disabling complication of pregnancy. Therefore, stroke and other vascular issues raise questions about the best evaluation and management that is safe for mother and child.

Seizures in pregnancy: epilepsy, eclampsia, and stroke

Seizures during pregnancy complicate <1% of all gestations; however, they are associated with increased adverse maternal and perinatal outcomes (acute and long term). The differential diagnosis of seizures in pregnancy is extensive. Determining the underlying etiology is crucial in the management of these patients. Medical providers caring for pregnant women should be educated about possible etiologies of seizures during pregnancy and the importance of prompt management of these women in a timely fashion. Evaluation and management should be performed in a stepwise fashion and may require a multidisciplinary approach with other specialties such as neurology. The objective of this review is to increase awareness and to provide a stepwise approach toward the diagnosis and management of pregnancies complicated by seizures.

[Do differences exist in the neurosurgical handling of intracranial lesions of pregnant patient? Outcomes of our experience and literature review]

OBJECTIVE

The main objective of our work is to revise our neurosurgical experience in pregnant patient and to carry out a revision of the related literature in order to optimize the neurosurgical handling of these kind of patients.

METHOD

Retrospective study between august 1993 and June 2010. We included patients who were pregnant at the time and who presented any trace of cranial neurosurgical or spinal disease.

RESULTS

The research includes the cases of 12 patients aged between 17 and 37 years old with an average age of 28.8 years old. The average gestation period was of 24.17 weeks, finding 50% of the patients within their third three-month period of pregnancy at the moment of diagnosis, 25% in their second three-month period and the remaining 25% in their first three-month period. The mean follow-up duration for this series was 84 months. 4 of them presented brain vascular lesions, 5 presented brain tumor lesions, 1 of them presented Chiari malformation, one lumbar disc herniation and 1 patient suffered from traumatic intracraneal hemorrhage. 8 of the 12 patients were subjected to neurosurgical procedures under general anesthetic, 2 for aneurysm embolizations and 2 for conservative treatments. Between the neurosurgical procedures 6 craniotomies were done, of wich 4 were to resection of the tumor and 2 for aneurysm clippings. There were done a transesfenoidal approach and a lumbar microdiscectomy. 2 of the 6 patients given craniotomies required external ventricular drainage before the operation. 5 elective cesareans were done in the group of patients given the craniotomies whilst of the rest the pregnancy was allowed to bring to term for reasons of pulmonary maturity. In our patients there were no cases of therapeutic abortion. There was found no morbidity no mortality neither in the mother nor in the fetus related to surgery.

CONCLUSIONS

In our experience with pregnant patients who suffered from neurosurgical lesion and in the experience we got from the revision of the related literature, the surgery of intracranial lesions is well tolerated by the mothers and the fetus. It must though be considered, the possibility of labor through cesarean depending on the fetus' lung maturity.

Atypical postpartum stroke presenting as opalski syndrome: case report and review of the literature

Background and Purpose

We present the first case of combined arterial (vertebral artery dissection) and venous [central sinus vein thrombosis (CSVT)] diseases presenting as Opalski syndrome in a female patient following induced delivery.

Case Description

A 32-year-old woman was admitted to our institute two weeks after induced delivery with intriguing neurological findings that were finally diagnosed as a combined venous-arterial disease. Although she was referred diagnosed with CSVT, her neurological findings indicated Wallenberg ‘plus’ syndrome with ipsilateral hemiparesis (Opalski syndrome), further confirmed by neuroimaging revealing arterial disease (vertebral artery dissection) combined with incidental acute CSVT. Coagulation, gynecological and cardiac problems were ruled out. Treatment consisted of continuous heparin with rigorous control of her blood pressure. Nine days later, the patient was discharged with prominent improvements. Most of the symptoms resolved following 3 months of rehabilitation.

Conclusions

Atypical strokes (such as Opalski syndrome) might present in postpartum patients. This rare diagnosis should be suspected in patients with Wallenberg ‘plus’ syndrome, and neuroimaging studies for determining the presence of arterial disease and brain stem lesions should be performed. Concomitant CSVT is rare and might mislead. Fine diagnosis followed by immediate conservative treatment can be of great benefit.

A rare case of antepartum posterior reversible encephalopathy syndrome

Pre-eclampsia and eclampsia are well-known causative factors of posterior reversible encephalopathy syndrome (PRES). There are only a few reported cases of antepartum PRES. We report a 25-year-old primigravid woman who presented with eight months of amenorrhoea and an abrupt onset of eclampsia associated with a history of a fall. A computed tomography scan ruled out intracranial haemorrhage and PRES was diagnosed. She responded well to supportive care, labour was induced and maternal and neonatal outcomes were good. Antepartum PRES poses different challenges to those of PRES in non-obstetric or postpartum patients, because of the additional management aspects required to ensure foetal wellbeing. We were posed with a difficult decision about the disadvantages of caesarean section versus those of vaginal delivery in our patient.

Ischemic Stroke during Pregnancy and Puerperium

Ischemic stroke during pregnancy and puerperium represents a rare occurrence but it could be a serious and stressful event for mothers, infants, and also families. Whenever it does occur, many concerns arise about the safety of the mother and the fetus in relation to common diagnostic tests and therapies leading to a more conservative approach. The physiological adaptations in the cardiovascular system and in the coagulability that accompany the pregnant state, which are more significant around delivery and in the postpartum period, likely contribute to increasing the risk of an ischemic stroke. Most of the causes of an ischemic stroke in the young may also occur in pregnant patients. Despite this, there are specific conditions related to pregnancy which may be considered when assessing this particular group of patients such as pre-eclampsia-eclampsia, choriocarcinoma, peripartum cardiomiopathy, amniotic fluid embolization, and postpartum cerebral angiopathy. This article will consider several questions related to pregnancy-associated ischemic stroke, dwelling on epidemiological and specific etiological aspects, diagnostic issue concerning the use of neuroimaging, and the related potential risks to the embryo and fetus. Therapeutic issues surrounding the use of anticoagulant and antiplatelets agents will be discussed along with the few available reports regarding the use of thrombolytic therapy during pregnancy.

Critical Care of Gynecological and Obstetric Patients: A decade of surgical intensive care experience

Despite the emergence of therapeutic advances, the morbidity and mortality still occur in the obstetric patients, although intensive care utilization by obstetric and gynecological patient, are still rare compared to the general population. Majority of obstetric patients needed the intensive care therapy compared to gynecological patients. The aim of our study was to know the indications for the intensive care admission by obstetric and gynecological patients, length of stay and outcome of these patients.

Methods: We retrospectively reviewed the medical records of all obstetric and gynecological patients admitted to our Surgical and Trauma Intensive Care Units (SICU and TICU) from February 1995 to March 2005. Indication for admission, nationality, age, and length of stay in ICU, severity of disease and outcome of these patients were recorded. Data analyzed with SPSS program.

Results: A total of 182 patients were admitted to the SICU of the Hamad Medical Corporation in Doha, Qatar, from the Women's Hospital. 159 (87%) patients were obstetric patients and 23 (13%) patients gynecological patients, 126 (69.6%) patients were admitted post Lower Segment Caesarean Section (LSCS). The most common indication for admission was 73 (39.3%) patients obstetric hemorrhage and Disseminated Intravascular Coagulation (DIC), and then 44 (25.3%) patients of hypertensive disorder of pregnancy. The major anesthesia related indication was scoline apnea, 21 (11.6%). Total three obstetric patients died, two due to severe sepsis and multi-organ failure and one due to cerebral sinus thrombosis, giving mortality rate of 1.66%.

Conclusion: Intensive care therapy required by gynecological and obstetric patient is less than the general population. The commonest indication for admission was obstetric hemorrhage, DIC, and hypertensive disorders of pregnancy. The mortality was due to septic shock with multi-organ failure, and cerebral venous sinus thrombosis.

Hydrocephalus after Intraventricular Hemorrhage in Eclamptic Woman with HELLP Syndrome

We report the first case of an obstructive hydrocephalus after intraventricular hemorrhage in a woman with HELLP syndrome and eclampsia. A 25-year-old primiparaous woman had severe preeclampsia at 36 weeks of gestation. She complained of epigastric pain and nausea. The levels of AST, ALT, and LDH were 539, 560, and 1051 IU/L, respectively; the platelet count was 101 x 109/L. Cesarean section was promptly performed. Intraoperatively, she had a first convulsion. The CT scan revealed only mild brain edema. The platelet count deteriorated to 30 x 109/L at 5 hour after the operation, and she had a second convulsion with an intraventricular hemorrhage. On the 6th post-cesarean day, she complained severe headache followed by coma. The CT scan revealed the enlargement of both lateral ventricles, indicating the occurrence of obstructive hydrocephalus. Drainage into cerebral ventricle was performed, resulting in the recovery of consciousness to a normal level.

Neurologic complications of pre-eclampsia

Pre-eclampsia is mainly responsible for the world's large maternal mortality rates, mostly due to acute cerebral complications. This review provides insight into the pathogenesis of the neurologic complications of hypertensive disease in pregnancy. In addition, practical relevance for clinical care is highlighted. Pertaining to pregnancy, the blood pressure level at which cerebral autoregulation operates and possible deregulation occurs is unknown, but is likely to be variable. From clinical observation, eclampsia may occur despite a mild clinical picture and before the development of hypertension or proteinuria. Furthermore, failure of cerebrovascular autoregulatory mechanisms in response to either an acute and/or relatively large blood pressure increase may be more important than the absolute blood pressure value. It may be the acuity of the blood pressure rise in the setting of endothelial dysfunction that interrupts the delicate balance between capillary and cellular perfusion pressures that leads to the neurological complications of pre-eclampsia.

The Risk of Aneurysmal Subarachnoid Hemorrhage During Pregnancy, Delivery, and the Puerperium in the Utrecht Population

Background and Purpose— It is unclear whether the risk of aneurysmal subarachnoid hemorrhage (aSAH) is increased during pregnancy, labor, and the puerperium. We compared the risk of aSAH during this period with the risk outside this period.

Methods— We included women with aSAH between 18 and 42 years of age (n=244) from our prospectively collected database of patients with subarachnoid hemorrhage treated in the University Medical Center Utrecht, the provincial referral center, between January 1987 and April 2006. We estimated the relative risk of aSAH during pregnancy, delivery, or the puerperium by a case-crossover design and calculated a standardized incidence ratio, dividing the observed number of patients with aSAH during pregnancy, delivery, or puerperium by the expected number based on the incidence in the general population of women of the same age during the study period.

Results— Of the 244 women, 4 were pregnant, 3 in the puerperium and none in labor. The relative risk of aSAH during pregnancy, delivery, or the puerperium was 0.4 (95% CI, 0.2 to 0.9). Based on the number of women aged 18 to 42 years within the catchment area of our hospital and the number of pregnancies within the study period, the expected number of patients with aSAH during pregnancy, delivery, or the puerperium was 12, resulting in a standardized incidence ratio of 0.6 (95% CI, 0.2 to 1.1).

Conclusions— The risk of aSAH is not increased during pregnancy, labor, and the puerperium. There is no need to advise against pregnancy in women with an increased risk of subarachnoid hemorrhage and no evidence to advise against vaginal delivery in such women.

Cerebrovascular diseases during pregnancy and puerperium

OBJECTIVE

We have studied 37 women with all forms of cerebrovascular diseases. Our aim was to study the etiology, clinical manifestations and prognosis of such conditions during pregnancy or puerperium.

METHODS

We analyzed the most common causes of cerebrovascular diseases during the given period.

RESULTS

The most common causes of cerebrovascular diseases during pregnancy or puerperium are hematological coagulation disorders, cardio embolism and eclampsia, whereas other causes ara rarer.

CONCLUSIONS

The incidence of cerebrovascular diseases during pregnancy or puerperium is 11%. Cerebrovascular diseases are more frequent in puerperium than during pregnancy, being 1.8:1. Etiology remains undetermined in 35% of the cases.

Postpartum intracranial hemorrhage disguised as preeclampsia

A 35-year-old woman, gravida 5 para 3, presented to the emergency department 9 days after a cesarean delivery with a new-onset headache, hypertension, and hyperreflexia. Formal urinalysis did not demonstrate proteinuria. Computed tomography of the brain demonstrated bilateral parietal subarachnoid hemorrhages. The patient was subsequently transferred to a tertiary care hospital where she underwent magnetic resonance imaging and computed tomographic angiography that were not suggestive of intracerebral aneurysm, arteriovenous malformation, sinus thrombosis, or angiopathy. The patient was treated with nimodipine and was successfully discharged without any neurologic sequelae or continued hypertension. This case illustrates the potential for presumed postpartum preeclampsia to mask other serious entities, such as intracranial hemorrhage.

Presentation, etiology, and outcome of stroke in pregnancy and puerperium

PURPOSE

The purpose of this study was to evaluate the presentation, timing, etiology, and outcome of ischemic stroke (IS), hemorrhagic stroke (HS), and cerebral venous thrombosis (CVT) occurring during pregnancy and puerperium at 3 Indianapolis hospitals.

METHODS

Medical records of patients with a stroke during pregnancy and the puerperium were identified by using International Classification of Diseases (ICD 9) codes and a computerized records database. The records were available from 1992 to 1999 at 2 of the hospitals and from 1994 to 1999 at the third hospital. The records were retrospectively reviewed for presentation, treatment, etiology, and outcome. The sample included all cases of IS, HS, and CVT occurring in our pregnant population and included events up to 12 weeks postpartum.

RESULTS

Thirty-six patients were identified, including 21 with IS, 11 with HS, and 4 patients with CVT. The majority of events (89%) occurred in the third trimester and postpartum period, and 16 of 36 (44%) events occurred in postpartum week 1. Of the 8 African American patients in our study, 5 had HS (63%), whereas 18 of the 25 white patients (72%) had IS. A definable cause was identified in 72% of IS and 82% of HS. Some causes of IS include pre-eclampsia or eclampsia (13%), cardioembolism (23%), and a diverse array of other causes, include hypercoagulable states, thrombotic thrombocytopenic purpura (TTP), cerebral vasculitis, cerebrovascular mucormycosis, and migrainous infarction. Pre-eclampsia/eclampsia (37%) and ruptured atriovenous malformation (AVM) (36%) were the primary causes of HS. None of the cases of CVT had a clear etiology other than the pregnant or puerperal state, although risk factors included systemic lupus erythematosus (negative antiphospholipid antibodies and lupus anticoagulant) in 1 patient and dehydration in a second. Hypertensive disorders of pregnancy were the most common comorbid conditions in both IS and HS, affecting 45% of those with IS and 64% of patients with HS. IS presented with focal deficits (76%), whereas HS tended to present with an altered level of consciousness (73%) and headache (64%). All patients with CVT (4/4) presented with a headache, and 2 of 4 patients presented with an altered level of consciousness. The majority of patients with HS were discharged to nursing homes or rehabilitation centers (63%), whereas 73% of patients with IS and 3 of 4 patients with CVT were discharged home. Only 1 death occurred in our study, because of a brain herniation after a massive hemispheric IS.

CONCLUSION

The etiology of stroke in pregnancy and the puerperium is diverse. Strokes are most likely to occur in the third trimester and postpartum period and cluster in the first postpartum week.

Maternal and neonatal outcome following cerebrovascular accidents during pregnancy

OBJECTIVE

To assess the clinical characteristics of maternal and neonatal outcome among women with cerebrovascular accidents (CVA) during pregnancy.

METHODS

Our computerized database was used to identify patients with CVA during pregnancy and puerperium from January 1988 to March 2004. Their medical records were identified and reviewed.

RESULTS

There were 16 cases of CVA among 173,803 deliveries, giving a risk of almost one case per 10,000 pregnant women. Out of 16 patients, 14 (88%) had a stroke and the remaining two cases were diagnosed with venous thrombosis. Of those 14 cases, nine (64%) had ischemic strokes and five (36%) had hemorrhagic strokes. Ten of the CVAs occurred antepartum, two intrapartum and four postpartum. Hypertensive disorders were diagnosed in 75% (12/16) of the patients. Out of these 12 patients with hypertension, 9 (75%) suffered from preeclampsia. One woman had a history of chronic hypertension. Smoking was associated with 63% (10/16) of the cases. There were two maternal deaths, both in women who had hemorrhagic strokes, and both in the first half of the study (1994 and 1996). Nine out of 16 women (56%), were delivered within 48 hours of the CVA including 7 (78%) antepartum, and two (22%) intrapartum. Cesarean deliveries were performed in 11/16 women (69%) including 8/10 with CVAs occurring antepartum, 1/2 intrapartum and 2/4 postpartum. One case of neonatal mortality was identified in a patient who was delivered at 24 gestational weeks.

CONCLUSIONS

(1) Hypertensive disorders and smoking were the most important factors associated with CVA during pregnancy. (2) Maternal mortality was high among patients with CVA during pregnancy. (3) Neonatal outcome was considered generally good in cases of CVA.

Posterior Reversible Encephalopathy Syndrome in a Patient with Severe Preeclampsia

Focal neurologic deficits in the parturient must be rapidly assessed and treated to minimize damage to both mother and child. The following case report features a patient presenting with visual loss, mental status changes, and severe preeclampsia, diagnosed as posterior reversible encephalopathy syndrome. This syndrome manifests radiographically as symmetric hypodensities of the posterior gray and white matter, and is usually reversible with prompt treatment.

Stroke complicating pregnancy and the puerperium

Stroke complicating pregnancy and the puerperium in Taiwan and the comparison between Western and Eastern countries have not been well studied. We identified retrospectively 32 cases of stroke from 66,781 deliveries, including 21 intracranial hemorrhages and 11 cerebral infarctions from 1992 to 2004. The most common causes of intracranial hemorrhage were vascular anomaly (29%), pre-eclampsia/eclampsia (24%), undetermined (24%) and coagulopathy (19%). The most common causes of cerebral infarction were cardioembolism (36%), cerebral venous thrombosis (27%) and pre-eclampsia/eclampsia (18%). Perinatal adverse outcome included two stillbirths, nine premature deliveries and four abortions. The compiled results of previous studies and ours revealed that intracranial hemorrhage appeared to be slightly more common in Taiwan (43-69%) than in the Western countries (33-52%). The average maternal mortality rate was 17.8% (range 9-38) with 77.8% due to intracranial hemorrhage. The average incidence of stroke associated with pregnancy and the puerperium was 21.3 per 100,000 deliveries (range 8.9-67.1). Our study, different from the Western countries, showed that intracranial hemorrhage is slightly more common than cerebral infarction. Pre-eclampsia/eclampsia is an important cause of stroke, however, the possibility of cardioembolism in cerebral infarction and vascular anomaly in intracranial hemorrhage should be studied.

Anesthetic management of the pregnant patient for endovascular coiling of an unruptured intracranial aneurysm

Diagnosis of an intracranial aneurysm during pregnancy is a rare event requiring multidisciplinary care for successful management. The knowledge base for the anesthesiologist involves principles of both obstetric and neuroanesthesia, as well as critical care. This article reports such a case and discusses the relevant pathophysiology, along with details of the perioperative management by the anesthesiology team.

Acute hypertensive emergencies in pregnancy

OBJECTIVE

Obstetrical hypertensive emergencies are life-threatening conditions involving significant risk to both the mother and fetus. Aggressive treatment of the maternal hypertensive state requires an initial consideration of the effect of treatment on the fetus, via changes to the uteroplacental circulation with treatment. The challenge then is to correct blood pressure using appropriate, safe pharmacologic agents to prevent catastrophic maternal consequences, while minimizing acute changes to placental perfusion and any corresponding fetal ill effects. Hypertension in pregnancy may be one manifestation of a multiple-system pathologic process, as is the case in preeclampsia. Blood pressure control, along with delivery, will be the first step in treating the renal, hematologic, hepatic, and cardiac dysfunction that can be seen in preeclampsia.

DESIGN

A review of medications most commonly used for hypertensive emergencies in pregnancy.

CONCLUSIONS

Hypertensive emergencies in pregnancy require prompt evaluation and treatment in an intensive care setting to prevent untoward effects to both the fetus and mother.

Pregnancy and stroke

The risks of ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage are not increased in the 9 months of gestation except for a high risk in the 2 days prior and 1 day postpartum. The remaining 6 weeks postpartum also have an increased risk of ischemic stroke and intracerebral hemorrhage, though less than the peripartum period. Although there are some rare causes of stroke specific to pregnancy and the postpartum period, eclampsia, cardiomyopathy, postpartum cerebral venous thrombosis, and, possibly, paradoxical embolism warrant special consideration. The diagnostic and therapeutic approaches to stroke during pregnancy and the postpartum period are similar to the approaches in the nonpregnant woman with some minor modifications based on consideration of the welfare of the fetus. There is a theoretical risk of magnetic resonance imaging exposure during the first and second trimester but the benefit to the mother of obtaining the information may outweigh the risk. Available evidence suggests that low-dose aspirin (<150 mg/day) during the second and third trimesters is safe for both mother and fetus. Postpartum use of low-dose aspirin by breast-feeding mother is also safe for infant. While proper counseling is imperative, a history of pregnancy-related stroke should not be a contraindication for subsequent pregnancy.

Diagnosis, prevention, and management of eclampsia

The pathogenesis of eclamptic convulsions remains unknown. Cerebral imaging suggests that cerebral abnormalities in eclampsia (mostly vasogenic edema) are similar to those found in hypertensive encephalopathy. However, cerebral imaging is not necessary for the diagnosis or management of most women with eclampsia. The onset of eclamptic convulsions can be antepartum (38-53%), intrapartum (18-36%), or postpartum (11-44%). Recent data reveal an increase in the proportion of women who develop eclampsia beyond 48 hours after delivery. Other than early detection of preeclampsia, there are no reliable tests or symptoms for predicting the development of eclampsia. In developed countries, the majority of cases reported in recent series are considered unpreventable. Magnesium sulfate is the drug of choice for reducing the rate of eclampsia developing intrapartum and immediately postpartum. There are 4 large randomized trials comparing magnesium sulfate with no treatment or placebo in patients with severe preeclampsia. The rate of eclampsia was significantly lower in those assigned to magnesium sulfate (0.6% versus 2.0%, relative risk 0.39, 95% confidence interval 0.28-0.55). Thus, the number of women needed to treat to prevent one case of eclampsia is 71. Magnesium sulfate is the drug of choice to prevent recurrent convulsions in eclampsia. The development of eclampsia is associated with increased risk of adverse outcome for both mother and fetus, particularly in the developing nations. Pregnancies complicated by eclampsia require a well-formulated management plan. Women with a history of eclampsia are at increased risk of eclampsia (1-2%) and preeclampsia (22-35%) in subsequent pregnancies. Recommendations for diagnosis, prevention, management, and counseling of these women are provided based on results of recent studies and my own clinical experience.

Brainstem ischemia and preeclampsia

Diffuse neurological manifestations of preeclampsia are due to endothelial involvement that lead to ischemia, hemorrhage, or edema. We analyzed clinical and radiological features and the course of brainstem ischemic strokes in a preeclampsia patient. We report a case of severe preeclampsia in a 30-year-old woman who was admitted 10 hr after a vaginal delivery at home. The pregnancy was at 39 wk, with no prenatal care. At her admission, she was conscious, and she had tetraparesia, swinging deep tendon reflex testing, drowsiness, and dysarthria; the BP was at 160/100 mmHg and 4 + proteinuria; magnetic resonance imaging revealed brainstem ischemic stroke. The evolution was favorable with symptomatic treatment. The patient was discharged on the 16th day; 2 months later she had a normal recovery. Brainstem strokes are rare. They are frequently due to hemorrhage; sometimes, they can also be ischemic. Their course is favorable.

Diagnosis and management of women with stroke during pregnancy/postpartum

Although the incidence of stroke is extremely low, the complications are serious. Maternal mortality has been reported to be as high as 26%. It is important for doctors to be aware of the causes, diagnostic techniques, and management strategies for stroke in order to achieve the best outcome for the mother and fetus. Recurrence risk appears extremely low, so women should feel confident in future positive pregnancy outcomes.

Stroke in pregnancy

Stroke in pregnancy and the puerperium is a rare but serious cause of maternal and fetal mortality. Pregnancy-associated maternal changes should remain additional considerations in the evaluation and treatment of the pregnant patient who has stroke and not preclude a comprehensive stroke evaluation. Instead, the approach to the pregnant patient who has stroke should include the evaluation of general causes of stroke in the young, with the additional consideration of the rare pregnancy-specific causes. Understanding the potential maternal and fetal risks of diagnostic testing and treatment is crucial to appropriate decision making when caring for the pregnant patient who has stroke.

Incidence and etiologies of stroke during pregnancy and puerperium as evidenced in Taiwanese women

BACKGROUND

Pregnancy is a known risk factor for stroke, but relatively few studies have been conducted in Asian populations to document the risk. This study aimed to analyze the incidence and etiologies of stroke occurring during pregnancy and puerperium in Taiwanese women.

METHODS

From 1984 to 2002, female patients 15 through 40 years of age with first-ever stroke during pregnancy or within 6 weeks of delivery were recruited. Stroke was classified as ischemic stroke (IS), cerebral venous thrombosis (CVT), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH). The incidence, time of stroke onset (1st through 3rd trimester or puerperium), and etiologies of different stroke subtypes were analyzed.

RESULTS

Of 402 young female stroke patients, 49 had stroke during pregnancy and puerperium, including 16 with IS, 11 with CVT, 19 with ICH and 3 with SAH. After excluding referral patients, the incidences of pregnancy-related stroke were 46.2 (95% CI 30.7-69.5) per 100,000 pregnancies. 67% developed stroke in the 3rd trimester and puerperium, and 73% of CVT occurred in the puerperium period. Etiologies were well defined in 78% of patients. Eclampsia (37%) and arteriovenous malformation (26%) were the most important etiologies of ICH. For IS and CVT, rheumatic heart disease (44%) and coagulopathy (64%) were the major etiologies respectively.

CONCLUSIONS

The incidence of stroke occurrence during pregnancy and puerperium in Taiwanese women is higher than that of Caucasian populations; the majority of strokes occurred in the 3rd trimester and puerperium, particularly CVT.

[Difficult decisions: headache treatment in pregnancy and childhood]

In pregnancy and in childhood, headache and migraine are challenging therapeutic problems.However, this review aims to give treatment recommendations for drug and non-drug therapy in both patient groups which are based on scientific evidence. Pregnant women often lose their migraine attacks which reappear during lactation. During pregnancy acute headache can be treated with paracetamol, in the middle trimenon also ASA and ibuprofen are allowed. Triptans for the acute treatment of migraine are contraindicated. As prophylactic agents, only metoprolol, fluoxetine, and magnesium are possible. In childhood, drug of first choice for acute headache treatment is ibuprofen. Migraine can also be treated by sumatriptan nasal spray. In migraine prophylaxis, flunarizine is drug of first choice, no prophylactic drugs are evaluated for tension-type headache in childhood. The problems of specific contraindications and of the off-label use of drugs in this particular life periods are discussed.