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Pohjola A, Vest T, Verho L, Aarnio K, Rantanen K, Laivuori H, Gissler M, Laakso A, Niemelä M, Ijäs P. Intracranial Arteriovenous Malformations During Pregnancy and Puerperium-A Retrospective Nationwide Population-Based Cohort Study. Neurosurgery 2024:00006123-990000000-01247. [PMID: 38934658 DOI: 10.1227/neu.0000000000003067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 05/03/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The knowledge about the management of patients with brain arteriovenous malformations (AVM) during pregnancy is limited, owing partly to insufficient evidence about the outcomes of newborns. This study aims to explore symptomatic AVMs and their outcomes during pregnancy, delivery, and the postpartum period. METHODS We conducted a retrospective analysis by combining patients with symptomatic AVM from a nationwide population-based cohort of all women with a pregnancy resulting in delivery during 1987 to 2016 (n = 1 773 728 deliveries) and our AVM database (n = 805, 1942-2014). Cerebrovascular events during pregnancy were identified through International Classification of Diseases-9, International Classification of Diseases-10, or surgical procedure codes from the Hospital Discharge and Medical Birth Registers. Our analysis focused on treatment characteristics and outcomes of patients with AVM hemorrhage or symptomatic AVM during pregnancy, delivery, or puerperium. RESULTS A total of 28 women with symptomatic AVMs during pregnancy, delivery, or postpartum period were followed for an average of 12.8 years (SD = 15.5) after admission. Among them, 21 (75%) experienced AVM hemorrhages during pregnancy, puerperium, or delivery. The mean age of patients was 28.9 years (SD = 5.5). Hemorrhages occurred predominantly during the second (n = 9, 43% of all ruptures) or the third trimester (n = 5, 24%). Two AVM ruptures occurred during labor. Treatment for AVM took place during pregnancy (n = 7, 25%) or puerperium (n = 3, 14%) in 10 patients (35.7%). Only 5 mothers (17.8%) had not been previously pregnant. There was no significant difference in mean Apgar scores between those with AVM hemorrhage (8.3) and those without (8.4). CONCLUSION Most mothers in the study had prior pregnancies, suggesting a potentially weaker association between AVM rupture and pregnancy compared to previous reports. Notably, 2 AVM ruptures occurred during spontaneous vaginal deliveries. Outcomes were generally favorable in both mothers and infants. More research is needed to refine our understanding of the optimal timing for invasive treatment during pregnancy.
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Affiliation(s)
- Anni Pohjola
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Teresa Vest
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Liisa Verho
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Karoliina Aarnio
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kirsi Rantanen
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hannele Laivuori
- Medical and Clinical Genetics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Institute for Molecular Medicine Finland, Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health Technology, Center for Child, Adolescent, and Maternal Health Research Tampere, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Mika Gissler
- Department of Knowledge Brokers, Finnish Institute for Health and Welfare, Helsinki, Finland
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Region Stockholm, Academic Primary Health Care Centre, Stockholm, Sweden
| | - Aki Laakso
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Mika Niemelä
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Petra Ijäs
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Schöberl F, Ringleb PA, Wakili R, Poli S, Wollenweber FA, Kellert L. Juvenile Stroke. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:527-534. [PMID: 28835326 DOI: 10.3238/arztebl.2017.0527] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 02/27/2017] [Accepted: 05/10/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND So-called juvenile stroke, i.e., stroke in a person aged 18 to 55, affects approximately 30 000 persons per year in Germany and is thus an important cause of mortality and permanent morbidity. The spectrum of causes of stroke is broader in this age group than in older patients and is also differently distributed. METHODS This review is based on pertinent publications retrieved by a selective search in PubMed and on current guideline recommendations. RESULTS Juvenile strokes are often caused by cardiogenic emboli (ca. 25%) and by vascular dissection (ca. 20%). Approximately 10% are due to rare causes such as vasculitis or thrombophilia, 25-50% remain cryptogenic, and 20-30% meet the criteria for an embolic stroke of undetermined source (ESUS). A rational diagnostic algorithm should be applied that is based on the relative frequencies of the potential causes. The acute treatment of ischemic stroke is the same for patients of all ages: the patient must be transferred as soon as possible to a hospital where a vascular recanalization procedure can be performed. From age 40 onward, there is a steep rise in vascular risk factors and therefore also in the resulting macro- and microangiopathy, which lead, in turn, to stroke. Only 40% of patients with juvenile stroke are ever able to return to their original occupation, and approximately one-third remain permanently unable to work. CONCLUSION The high rates of cryptogenic stroke and ESUS among patients with juvenile stroke indicate that uncertainties remain in the diagnosis and treatment of this entity. The identification of rare causes of juvenile stroke requires a major diagnostic effort. Which diagnostic tests are useful or necessary in which patients is a matter that is currently decided on an individual basis. This is true, above all, of the indication for long-term cardiac monitoring.
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Affiliation(s)
- Florian Schöberl
- Neurological Clinic and Policlinic, Großhadern Hospital, Ludwig-Maximilians-Universität München; Neurological Clinic, Heidelberg University Hospital; Medical Clinic and Policlinic I, Großhadern Hospital, Ludwig-Maximilians-Universität München; German Centre for Cardiovascular Research (DZHK), partner site Munich Heart Alliance, München; Department of Cardiology and Angiology, Westdeutsches Herz- und Gefäßzentrum Essen, Essen University Hospital; Clinic of Neurology, Hertie Institute for Clinical Brain Research (HIH), University Hospital Tübingen; Institute for Stroke and Dementia Research (ISD), Großhadern Hospital, Ludwig-Maximilians-Universität München
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Jagodzińska A, Gondek A, Pietrzak B, Cudnoch-Jędrzejewska A, Mamcarz A, Wielgoś M. Peripartum cardiomyopathy - from pathogenesis to treatment. J Perinat Med 2018; 46:237-245. [PMID: 28489560 DOI: 10.1515/jpm-2016-0247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Aleksandra Jagodzińska
- Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, Banacha 1b, 02-097 Warsaw, Poland
- First Department of Obstetrics and Gynecology, Medical University of Warsaw, Pl. Starynkiewicza 1/3, 02-015 Warsaw, Poland
| | - Agata Gondek
- Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, Banacha 1b, 02-097 Warsaw, Poland
| | - Bronisława Pietrzak
- First Department of Obstetrics and Gynecology, Medical University of Warsaw, Pl. Starynkiewicza 1/3, 02-015 Warsaw, Poland
| | - Agnieszka Cudnoch-Jędrzejewska
- Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, Banacha 1b, 02-097 Warsaw, Poland
| | - Artur Mamcarz
- Third Department of Internal Medicine and Cardiology Medical University of Warsaw, Solec 93, Warsaw, Poland
| | - Mirosław Wielgoś
- First Department of Obstetrics and Gynecology, Medical University of Warsaw, Pl. Starynkiewicza 1/3, 02-015 Warsaw, Poland
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Park Y, Cho GJ, Kim LY, Lee TS, Oh MJ, Kim YH. Preeclampsia Increases the Incidence of Postpartum Cerebrovascular Disease in Korean Population. J Korean Med Sci 2018; 33:e35. [PMID: 29349936 PMCID: PMC5777915 DOI: 10.3346/jkms.2018.33.e35] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 11/20/2017] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Multiple studies have been reported regarding preeclampsia as a possible risk factor of cerebrovascular disease (CVD). However, the correlation of preeclampsia and CVD, whether it is a cause-effect relationship or they are sharing common predisposing condition, is not well understood. Therefore, the aim of this study was to investigate the association between the preeclampsia during pregnancy and development of postpartum CVD. METHODS A total of 1,384,550 Korean women who had a delivery between January 1, 2010 and December 31, 2012, were enrolled. Women with the risk of CVD within 1 year prior to pregnancy were excluded based on the Charlson comorbidity index. Primary endpoint was the event of CVD within a year from delivery. After exclusion, 1,075,061 women were analyzed. RESULTS During the follow-up of 1 year postpartum, there were 25,577 preeclampsia out of 1,072,041 women without postpartum CVD (2.39%), and 121 of 3,020 women with postpartum CVD had preeclampsia before delivery (4.01%). In multivariate logistic regression analysis, women who had preeclampsia during pregnancy showed a higher risk for postpartum CVD (odds ratio, 1.64; 95% confidence interval, 1.37-1.98). CONCLUSION The incidence of CVD after delivery was higher in women who had preeclampsia during pregnancy.
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Affiliation(s)
- Yejin Park
- Department of Obstetrics and Gynecology, Yonsei University College of Medicine, Seoul, Korea
- Institute of Women's Life Medical Science, Yonsei University Health System, Seoul, Korea
| | - Geum Joon Cho
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Korea
| | - Log Young Kim
- Healthcare Data Convergence Department, Health Insurance Review and Assessment Service, Seoul, Korea
| | - Tae Seon Lee
- Healthcare Data Convergence Department, Health Insurance Review and Assessment Service, Seoul, Korea
| | - Min Jeong Oh
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Korea
| | - Young Han Kim
- Department of Obstetrics and Gynecology, Yonsei University College of Medicine, Seoul, Korea
- Institute of Women's Life Medical Science, Yonsei University Health System, Seoul, Korea.
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Abstract
OPINION STATEMENT Optimal diagnosis and management of stroke in young adults benefit from a multidisciplinary team, including a vascular neurology specialist. In addition to the "standard" vascular risk factors including smoking, hypertension, diabetes, and hyperlipidemia, one needs to consider alternative etiologies including substance abuse, carotid/vertebral artery dissections, and rare genetic conditions among others. Once a young patient is determined to have had a stroke, the next question a clinician should ask is why did this patient have a stroke? A "heart to head" diagnostic approach is recommended. A thorough history is performed, including a detailed family history with specific annotations on each family member. A thorough physical examination is necessary including a careful evaluation of the patient's general appearance, noting any joint laxity, and/or abnormalities of the skin, eyes, and heart. Findings across multiple organ systems in the patient and/or their family may indicate a genetic etiology. After an initial head CT rules out hemorrhagic stroke, additional testing should include a brain MRI, neck and cerebral vascular imaging (e.g., CTA for head and neck), transthoracic echocardiogram with a bubble study, telemetry monitoring, basic risk factor blood work (e.g., lipid panel, hemoglobin A1c, TSH, ESR, CRP, RPR, HIV, and toxicology screen), and, when appropriate, sickle screen and pregnancy test. There should be a low threshold to obtain blood cultures or a lumbar puncture. The acute treatment of ischemic stroke in young adult patients does not differ from treatment of older adults, using intravenous alteplase within 4.5 h, assuming no contraindications. In suspected proximal large artery occlusive disease, interventional clot extraction procedures should be employed in patients deemed eligible. Long-term secondary prevention strategies aimed to reduce recurrent stroke risk by targeting and modifying vascular risk factors should be instituted. The mainstay of preventative therapy is aspirin for most etiologies; however, for atrial fibrillation, anticoagulation is recommended. Statin therapy is another pharmacologic intervention recommended in most stroke patients. Other measures employed are blood pressure reduction, smoking cessation, optimal glucose control in diabetic patients, the initiation of a healthy diet and regular exercise, and lastly, substance abuse counseling in appropriate patients.
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Affiliation(s)
- Christopher A Stack
- Department of Neurology, University of Maryland Medical Center, 16 South Eutaw Street Suite 300, Baltimore, MD, 21201, USA
| | - John W Cole
- Department of Neurology, Baltimore VA Medical Center, University of Maryland School of Medicine, 12th Floor, Bressler Building, Room 12-006, 655 West Baltimore Street, Baltimore, MD, 21201-1559, USA.
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Abstract
Stroke in young adults is a diagnostic and therapeutic challenge for all persons involved. Approximately 15% of ischemic strokes occur in young adults. Lack of awareness of the symptoms in emergency departments often results in delayed diagnosis and access to specific therapeutic options, such as revascularization. The causes are often heterogeneous and necessitate specific investigations. The etiology of juvenile stroke includes drug abuse, vasculitis and arteriopathies, such as reversible vasoconstriction syndrome and posterior reversible encephalopathy syndrome, although the prevalence of classical vascular risk factors is high. The most frequent causes of ischemic stroke in young adults are cardioembolism and microangiopathy; furthermore, dissection of vessels of the neck are more frequent compared to older patients. According to the results of currently available studies reperfusion strategies, such as intravenous fibrinolysis and mechanical thrombectomy are efficacious and safe in young patients.
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Affiliation(s)
- M Fischer
- Neurologie, Asklepios Klinik Altona, Paul-Ehrlich-Straße 1, 22763, Hamburg, Deutschland.
| | - B Eckert
- Neurologie, Asklepios Klinik Altona, Paul-Ehrlich-Straße 1, 22763, Hamburg, Deutschland
| | - J Röther
- Neurologie, Asklepios Klinik Altona, Paul-Ehrlich-Straße 1, 22763, Hamburg, Deutschland
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Peripartum Cardiomyopathy: Do Exosomes Play a Role? ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 998:139-149. [PMID: 28936737 DOI: 10.1007/978-981-10-4397-0_9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Peripartum cardiomyopathy (PPCM) refers to irreversible cardiomyocyte damage that occurs during the last month of pregnancy, or within 5 months after giving birth. It is characterized by systolic heart failure. This life-threatening condition is relatively uncommon, but the incidence has been climbing up. Because of its high mortality, it is crucial for physicians to have high suspicious for the disease. Studies have been done to search into specific lab test and treatment for PPCM. Therapies like anti-viral, anti-inflammatory and immunosuppression regimen have been explored. New regimen like exosomes has also been explored and revealed promising effects.
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8
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Accidenti vascolari cerebrali nella donna. Neurologia 2016. [DOI: 10.1016/s1634-7072(16)80383-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Dubbs SB, Tewelde SZ. Cardiovascular Catastrophes in the Obstetric Population. Emerg Med Clin North Am 2015; 33:483-500. [DOI: 10.1016/j.emc.2015.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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10
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Frontera JA, Ahmed W. Neurocritical care complications of pregnancy and puerperum. J Crit Care 2014; 29:1069-81. [PMID: 25123793 DOI: 10.1016/j.jcrc.2014.07.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 06/02/2014] [Accepted: 07/08/2014] [Indexed: 12/27/2022]
Abstract
Neurocritical care complications of pregnancy and puerperum such as preeclampsia/eclampsia, hemolysis, elevated liver enzymes, low platelets syndrome, thrombotic thrombocytopenic purpura, seizures, ischemic and hemorrhagic stroke, postpartum angiopathy, cerebral sinus thrombosis, amniotic fluid emboli, choriocarcinoma, and acute fatty liver of pregnancy are rare but can be devastating. These conditions can present a challenge to physicians because pregnancy is a unique physiologic state, most therapeutic options available in the intensive care unit were not studied in pregnant patients, and in many situations, physicians need to deliver care to both the mother and the fetus, simultaneously. Timely recognition and management of critical neurologic complications of pregnancy/puerperum can be life saving for both the mother and fetus.
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Affiliation(s)
- Jennifer A Frontera
- Cerebrovascular Center of the Neurological Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Wamda Ahmed
- Neuroscience Intensive Care Unit, Departments of Neurology, Emory, Atlanta, Georgia
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Sliwa K, Hilfiker-Kleiner D, Petrie MC, Mebazaa A, Pieske B, Buchmann E, Regitz-Zagrosek V, Schaufelberger M, Tavazzi L, van Veldhuisen DJ, Watkins H, Shah AJ, Seferovic PM, Elkayam U, Pankuweit S, Papp Z, Mouquet F, McMurray JJ. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur J Heart Fail 2014; 12:767-78. [PMID: 20675664 DOI: 10.1093/eurjhf/hfq120] [Citation(s) in RCA: 591] [Impact Index Per Article: 59.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Karen Sliwa
- Hatter Cardiovascular Research Institute; University of Cape Town; Cape Town South Africa
| | | | - Mark C. Petrie
- Golden Jubilee National Hospital; West of Scotland Regional Heart Centre; Glasgow UK
| | - Alexandre Mebazaa
- Inserm U 942, Hôpital Lariboisière; Université Paris Diderot; Paris France
| | - Burkert Pieske
- Deparment of Cardiologie; Medical University Graz; Graz Austria
| | - Eckhart Buchmann
- Department of Obstetrics and Gynaecology; University of the Witwatersrand and Chris Hani Baragwanath Hospital; Johannesburg South Africa
| | | | - Maria Schaufelberger
- Department of Medicine; Sahlgrenska University Hospital Ostra; Gothenburg Sweden
| | - Luigi Tavazzi
- Maria Cecilia Hospital - GVM Care & Research; Ettore Sansavini Health Science Foundation; Cotignola Italy
| | - Dirk J. van Veldhuisen
- Department of Cardiology; University Medical Center Groningen; Groningen The Netherlands
| | - Hugh Watkins
- University of Oxford; John Radcliffe Hospital; Oxford UK
| | - Ajay J. Shah
- BHF Centre of Excellence; UK King's College London; UK
| | | | - Uri Elkayam
- Keck School of Medicine; University of Southern California; Los Angeles CA USA
| | - Sabine Pankuweit
- Department of Internal Medicine/Cardiology; Philipp's University Marburg; Marburg Germany
| | - Zoltan Papp
- Division of Clinical Physiology, Faculty of Medicine, Institute of Cardiology; University of Debrecen, Medical and Health Science Center; Debrecen Hungary
| | - Frederic Mouquet
- Polyclinique du Bois, et Pole des maladies cardiovasculaires; Hoptial Cardiologique, Centre Hospitalier Universitaire; Lille France
| | - John J.V. McMurray
- British Heart Foundation Cardiovascular Research Centre; University of Glasgow; Glasgow UK
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Foo L, Bewley S, Rudd A. Maternal death from stroke: a thirty year national retrospective review. Eur J Obstet Gynecol Reprod Biol 2013; 171:266-70. [DOI: 10.1016/j.ejogrb.2013.09.021] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2013] [Revised: 09/09/2013] [Accepted: 09/18/2013] [Indexed: 10/26/2022]
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Shah T, Ather S, Bavishi C, Bambhroliya A, Ma T, Bozkurt B. Peripartum cardiomyopathy: a contemporary review. Methodist Debakey Cardiovasc J 2013; 9:38-43. [PMID: 23519269 DOI: 10.14797/mdcj-9-1-38] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Peripartum cardiomyopathy is a rare and potentially fatal disease. Though approximately half of the patients recover, the clinical course is highly variable and some patients develop refractory heart failure and persistent left ventricular systolic dysfunction. It is diagnosed when women present with heart failure secondary to left ventricular systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause of heart failure is found. Etiology remains unclear, and treatment is similar to other cardiomyopathies and includes evidence-based standard heart failure management strategies. Experimental strategies such as intravenous immunoglobulin and bromocriptine await further clinical validation.
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Affiliation(s)
- Tina Shah
- Baylor College of Medicine, Houston, Texas, USA
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14
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SJ A, A B, Hussein OM, RA A. Stroke in the postpartum period: a case study. J Clin Diagn Res 2013; 7:1183-5. [PMID: 23905136 PMCID: PMC3708231 DOI: 10.7860/jcdr/2012/5235.3051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Accepted: 01/28/2013] [Indexed: 11/24/2022]
Abstract
A twenty six years old woman presented with visual disturbance, headache and gait disturbance ten weeks postpartum. Imaging studies identified an acute infarction in the left thalamus. This case report discusses her presentation, investigations and management and the aetiology of stroke in pregnancy and the postpartum period.
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Affiliation(s)
- Allison SJ
- Eastwood Stroke Unit, Chesterfield Royal Hospital NHS Foundation Trust, Calow, Chesterfield, Derbyshire, S44 5BL, UK
| | - Basit A
- Eastwood Stroke Unit, Chesterfield Royal Hospital NHS Foundation Trust, Calow, Chesterfield, Derbyshire, S44 5BL, UK
| | - Omer Mohd Hussein
- Department of Psychiatry, Faculty of Medicine, National Ribat University, Khartoum, Sudan
| | - Ahmed RA
- Eastwood Stroke Unit, Chesterfield Royal Hospital NHS Foundation Trust, Calow, Chesterfield, Derbyshire, S44 5BL, UK
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15
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Abstract
There is an increased risk of strokes in pregnancy and puerperium. Intracranial haemorrhage is the rarer of the two stroke subtypes but carries a greater morbidity and mortality for both the mother and the child. This review highlights the causes of pregnancy-related intracranial haemorrhage and its management. The incidence varies from region to region with the highest being reported from China and Taiwan. Majority of these haemorrhages are secondary to hypertensive disorders of pregnancy with smaller proportions related to aneurysm and arteriovenous malformation rupture. A small but important contributor is cortical venous thrombosis which, although predominantly gives rise to ischaemic lesions, may lead to parenchymal haemorrhages as well. Presentation is usually with headaches or seizures, with or without focal deficits. Diagnosis requires brain imaging with computerized tomography or magnetic resonance imaging, and the necessity of investigation when this diagnosis is suspected supersedes the small risk of fetal malformation. Management follows the general management principles for intracranial haemorrhage management. Blood pressures need to be strictly monitored and medicines used for controlling them may differ slightly due to teratogenic effects. For preeclampsia, early but safe delivery is the best treatment. For cortical venous thrombosis, low-molecular-weight heparin is the preferred agent. Aneurysms and vascular malformations need to be definitively treated to prevent re-bleed and this can be achieved through surgical or endovascular procedures. The timing of surgery depends on neurosurgical considerations. However, the timing and mode of delivery are governed by obstetric factors. Risk of future haemorrhage depends on whether the underlying aetiology can be and has been definitively treated.
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Affiliation(s)
- Maria Khan
- Department of Neurology (Medicine), Aga Khan University, Karachi, Pakistan
| | - Mohammad Wasay
- Department of Neurology (Medicine), Aga Khan University, Karachi, Pakistan
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16
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Mandal D, Mandal S, Mukherjee D, Biswas SC, Maiti TK, Chattopadhaya N, Majumdar B, Panja M. Pregnancy and subsequent pregnancy outcomes in peripartum cardiomyopathy. J Obstet Gynaecol Res 2010; 37:222-7. [PMID: 21114580 DOI: 10.1111/j.1447-0756.2010.01378.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AIM To study the clinical profile and management of peripartum cardiomyopathy, and to analyze the pregnancy outcomes of pregnant women with this disorder as well as its effect on subsequent pregnancies. METHODS All patients admitted with peripartum cardiomyopathy from July 2006 to June 2009 by the Departments of Cardiology and Obstetrics and Gynecology from the Institute of Post Graduate Medical Education and Research, Kolkata, India, were considered for this observational study. Thirty-six women with 42 pregnancies (36 first pregnancies and six second pregnancies in the same patients) were evaluated. RESULTS Primiparas constituted 39% (14/36) of the total study population. Twenty-six women (72%) were clinically improved and in 17 (48%) the left ventricular functional status returned to normal. Five cases (14%) developed persistent cardiomyopathy (persistent left ventricular dysfunction beyond six months of presentation), and five women (14%) presented with thromboembolic events and anticoagulation was used as secondary prophylaxis. Maternal mortality was 14% (5/36). Among all live babies two had intrauterine growth restriction (IUGR) and another two died during the neonatal period. Of the six women with subsequent pregnancies, the patient with persistent cardiomyopathy died after delivering a stillborn baby. The remaining five cases with normal left ventricular functional status had favorable fetal outcomes; however, the mothers experienced morbidities such as symptoms of heart failure (two cases) and one of them progressed to persistent cardiomyopathy. CONCLUSIONS Subsequent pregnancies should be discouraged as it increases the risk of recurrence of left ventricular dysfunction. Anticoagulation may be considered as a primary prevention of thromboembolism in pregnant mothers with peripartum cardiomyopathy.
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Affiliation(s)
- Debasmita Mandal
- Department of Obstetrics and Gynecology, Institute of Post Graduate Medical Education and Research, Kolkata, India.
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Herbst J, Winskog C, Byard RW. Cardiovascular Conditions and the Evaluation of the Heart in Pregnancy-Associated Autopsies. J Forensic Sci 2010; 55:1528-33. [DOI: 10.1111/j.1556-4029.2010.01489.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ferro JM, Massaro AR, Mas JL. Aetiological diagnosis of ischaemic stroke in young adults. Lancet Neurol 2010; 9:1085-96. [DOI: 10.1016/s1474-4422(10)70251-9] [Citation(s) in RCA: 179] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Calado S, Viana-Baptista M. Benign cerebral angiopathy; postpartum cerebral angiopathy: characteristics and treatment. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2010; 8:201-12. [PMID: 16635439 DOI: 10.1007/s11936-006-0013-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Benign cerebral angiopathy and postpartum cerebral angiopathy are reversible cerebral arterial vasoconstriction syndromes. Presentation includes recurrent severe headaches, altered consciousness, and focal neurologic deficits; ischemic and/or hemorrhagic strokes can occur. No standard management has been established, but most authors agree that 1) acute-phase treatment includes cessation of vasoconstrictors, treatment of associated conditions, vasospasm treatment (calcium channel antagonists), and corticosteroids; 2) other measures include headache relief, blood pressure control, and stroke, cerebral edema, and seizure treatment; 3) definitive diagnosis requires conventional angiography and exclusion of alternative diagnosis; 4) a second arterial examination after 4 to 6 weeks is mandatory to confirm reversibility of vasoconstriction; 5) brain biopsy is indicated to rule out cerebral vasculitis in severe cases with clinical deterioration under steroid treatment or atypical findings; 6) immunosuppression should be reserved for patients with brain-leptomeningeal biopsy-proven vasculitis or used while waiting for a brain biopsy result; and 7) long-term measures include secondary stroke prevention and treatment of complications.
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Affiliation(s)
- Sofia Calado
- Serviço Universitário de Neurologia, Hospital de Egas Moniz, Rua da Junqueira 126, Lisbon 1349-019, Portugal.
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Lata I, Gupta R, Sahu S, Singh H. Emergency management of decompensated peripartum cardiomyopathy. J Emerg Trauma Shock 2009; 2:124-8. [PMID: 19561973 PMCID: PMC2700591 DOI: 10.4103/0974-2700.50748] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2008] [Accepted: 11/22/2008] [Indexed: 12/16/2022] Open
Abstract
Peripartum cardiomyopathy (PPCM) is a rare life-threatening cardiomyopathy of unknown cause that occurs in the peripartum period in previously healthy women.[1] the symptomatic patients should receive standard therapy for heart failure, managed by a multidisciplinary team. The diagnosis of PPCM rests on the echocardiographic identification of new left ventricular systolic dysfunction during a limited period surrounding parturition. Diagnostic criteria include an ejection fraction of less than 45%, fractional shortening of less than 30%, or both, and end-diastolic dimension of greater than 2.7 cm/m(2) body surface-area. This entity presents a diagnostic challenge because many women in the last month of a normal pregnancy experience dyspnea, fatigue, and pedal edema, symptoms identical to early congestive heart failure. There are no specific criteria for differentiating subtle symptoms of heart failure from normal late pregnancy. Therefore, it is important that a high index of suspicion be maintained to identify the rare case of PPCM as general examination showing symptoms of heart failure with pulmonary edema. PPCM remains a diagnosis of exclusion. No additional specific criteria have been identified to allow distinction between a peripartum patient with new onset heart failure and left ventricular systolic dysfunction as PPCM and another form of dilated cardiomyopathy. Therefore, all other causes of dilated cardiomyopathy with heart failure must be systematically excluded before accepting the designation of PPCM. Recent observations from Haiti[2] suggest that a latent form of PPCM without clinical symptoms might exist. The investigators identified four clinically normal postpartum women with asymptomatic systolic dysfunction on echocardiography, who subsequently either developed clinically detectable dilated cardiomyopathy or improved and completely recovered heart function.
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Affiliation(s)
- Indu Lata
- Department of Obstetrics and Gynaecology V.M.M.C and Safdarjung Hospital, N. Delhi, India
| | - Renu Gupta
- Department of Obstetrics and Gynaecology, G.S.V.M. Medical College, Kanpur, India
| | - Sandeep Sahu
- Department of Anaesthesiology, G.S.V.M. Medical College, Kanpur, India
| | - Harpreet Singh
- Department of Anaesthesiology, G.S.V.M. Medical College, Kanpur, India
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Vega-Basulto S, Lafontaine-Terry E, Gutiérrez-Muñoz F, Roura-Carrasco J, Pardo-Camacho G. Hemorragia intracraneal por aneurismas y malformaciones arteriovenosas durante el embarazo y el puerperio. Neurocirugia (Astur) 2008. [DOI: 10.1016/s1130-1473(08)70245-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Peripartum cardiomyopathy (PPCM) is a disorder in which initial left ventricular systolic dysfunction and symptoms of heart failure occur between the late stages of pregnancy and the early postpartum period. It is common in some countries and rare in others. The causes and pathogenesis are poorly understood. Molecular markers of an inflammatory process are found in most patients. Clinical presentation includes usual signs and symptoms of heart failure, and unusual presentations relating to thromboembolism. Clinicians should consider PPCM in any peripartum patient with unexplained disease. Conventional heart failure treatment includes use of diuretics, beta blockers, and angiotensin-converting enzyme inhibitors. Effective treatment reduces mortality rates and increases the number of women who fully recover left ventricular systolic function. Outcomes for subsequent pregnancy after PPCM are better in women who have first fully recovered heart function. Areas for future research include immune system dysfunction, the role of viruses, non-conventional treatments such as immunosuppression, immunoadsorption, apheresis, antiviral treatment, suppression of proinflammatory cytokines, and strategies for control and prevention.
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Affiliation(s)
- Karen Sliwa
- Soweto Cardiovascular Research Unit, Department of Cardiology, Chris-Hani-Baragwanath Hospital, University of the Witwatersrand, P O Bertsham 2013, Johannesburg, South Africa.
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