The Canadian Stroke Best Practice Consensus Statement Acute Stroke Management during Pregnancy is the second of a two-part series devoted to stroke in pregnancy. The first part focused on the unique aspects of secondary stroke prevention in a woman with a prior history of stroke who is, or is planning to become, pregnant. This document focuses on the management of a woman who experiences an acute stroke during pregnancy. This consensus statement was developed in recognition of the need for a specifically tailored approach to the management of this group of patients in the absence of any broad-based, stroke-specific guidelines or consensus statements, which do not exist currently. The foundation for the development of this document was the concept that maternal health is vital for fetal well-being; therefore, management decisions should be based first on the confluence of two clinical considerations: (a) decisions that would be made if the patient wasn't pregnant and (b) decisions that would be made if the patient hadn't had a stroke, then nuanced as needed. While empirical research in this area is limited, this consensus document is based on the best available literature and guided by expert consensus. Issues addressed in this document include initial emergency management, diagnostic imaging, acute stroke treatment, the management of hemorrhagic stroke, anesthetic management, post stroke management for women with a stroke in pregnancy, intrapartum considerations, and postpartum management. These statements are appropriate for healthcare professionals across all disciplines and system planners to ensure pregnant women who experience a stroke have timely access to both expert neurological and obstetric care.
Statistics Canada. Table 102–0561—Leading causes of death, total population, by age group and sex, Canada. CANSIM (death database). Ottawa: Statistics Canada.
2.
DemelSLKittnerSLeySHMcDermottMRexrodeKM. Stroke risk factors unique to women. Stroke2018; 49: 518–523.
3.
CordonnierCSpriggNSandsetECet al.Stroke in women—from evidence to inequalities. Nat Rev Neurol2017; 13: 521–532.
4.
SwartzRHCayleyMLFoleyNet al.The incidence of pregnancy-related stroke: a systematic review and meta-analysis. Int J Stroke2017; 12: 687–697.
5.
SinghalABBillerJElkindMSet al.Recognition and management of stroke in young adults and adolescents. Neurology2013; 81: 1089–1097.
6.
LeffertLRClancyCRBatemanBTBryantASKuklinaEV. Hypertensive disorders and pregnancy-related stroke: frequency, trends, risk factors, and outcomes. Obstet Gynecol2015; 125: 124–131.
7.
SwartzRHLadhaniNNNFoleyNet al.Canadian Stroke Best Practice Consensus Statement: secondary stroke prevention during pregnancy. Int J Stroke2018; 13: 406–419.
8.
Rosene-MontellaKKeelyEBarbourLLeeR. Medical care of the pregnant patient, Philadelphia, PA: American College of Physicians Press, 2008.
9.
CouttsSBWeinTHLindsayMPet al.Canadian Stroke Best Practice Recommendations: secondary prevention of stroke guidelines, update 2014. Int J Stroke2015; 10: 282–291.
10.
MageeLAPelsAHelewaMReyEvon DadelszenP. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy: executive summary. J Obstet Gynaecol Can2014; 36: 416–441.
11.
ChanWSReyEKentNEet al.Venous thromboembolism and antithrombotic therapy in pregnancy. J Obstet Gynaecol Can2014; 36: 527–553.
12.
DaviesGAMaxwellCMcLeodLet al.SOGC clinical practice guidelines: obesity in pregnancy. No. 239, February 2010. Int J Gynaecol Obstet2010; 110: 167–173.
13.
LindsayMP, Gubitz GGBayleyMPhillipsSSmithEE. Canadian Stroke Best Practice Recommendations overview and methodology. On behalf of the Canadian Stroke Best Practices Advisory Committee and Writing Groups, Ottawa: Heart and Stroke Foundation, 2014.
14.
ButaliaSAudibertFCôtéA-Met al.Hypertension Canada's 2018 guidelines for the management of hypertension in pregnancy. Can J Cardiol2018; 34: 526–531.
15.
MartinJNJrThigpenBDMooreRCRoseCHCushmanJMayW. Stroke and severe preeclampsia and eclampsia: a paradigm shift focusing on systolic blood pressure. Obstet Gynecol2005; 105: 246–254.
16.
NerenbergKAZarnkeKBLeungAAet al.Hypertension Canada's 2018 guidelines for diagnosis #risk |assessment, prevention, and treatment of hypertension in adults and children. Can J Cardiol2018; 34: 506–525.
17.
MacgregorEA. Headache in pregnancy. Continuum (Minneap Minn)2014; 20: 128–147.
18.
RayJGVermeulenMJBharathaAMontaneraWJParkAL. Association between MRI exposure during pregnancy and fetal and childhood outcomes. JAMA2016; 316: 952–961.
19.
Committee Opinion No. 723. Guidelines for diagnostic imaging during pregnancy and lactation. Obstet Gynecol2017; 130: e210–e6.
20.
TremblayETherasseEThomassin-NaggaraITropI. Quality initiatives: guidelines for use of medical imaging during pregnancy and lactation. Radiographics2012; 32: 897–911.
21.
RatnapalanSBenturYKorenG. Doctor, will that x-ray harm my unborn child?. CMAJ2008; 179: 1293–1296.
McColloughCHSchuelerBAAtwellTDet al.Radiation exposure and pregnancy: when should we be concerned?. Radiographics2007; 27: 909–917. discussion 917–918.
24.
TiradaNDreizinDKhatiNJAkinEAZemanRK. Imaging pregnant and lactating patients. Radiographics2015; 35: 1751–1765.
25.
PatenaudeYPugashDLimKet al.The use of magnetic resonance imaging in the obstetric patient. J Obstet Gynaecol Can2014; 36: 349–363.
26.
ElfordKLeaderAWeeRStysPK. Stroke in ovarian hyperstimulation syndrome in early pregnancy treated with intra-arterial rt-PA. Neurology2002; 59: 1270–1272.
27.
LiYMargrafJKluckBJennyDCastaldoJ. Thrombolytic therapy for ischemic stroke secondary to paradoxical embolism in pregnancy: a case report and literature review. Neurologist2012; 18: 44–48.
28.
TverskySLibmanRBReppucciMLTufanoAMKatzJM. Thrombolysis for ischemic stroke during pregnancy: a case report and review of the literature. J Stroke Cerebrovasc Dis2016; 25: e167–70.
29.
WieseKMTalkadAMathewsMWangD. Intravenous recombinant tissue plasminogen activator in a pregnant woman with cardioembolic stroke. Stroke2006; 37: 2168–2169.
30.
TassiRAcampaMMarottaGet al.Systemic thrombolysis for stroke in pregnancy. Am J Emerg Med2013; 31: 448. e1-3.
31.
LandaisAChaumontHDellisR. Thrombolytic Therapy of Acute Ischemic Stroke during Early Pregnancy. J Stroke Cerebrovasc Dis J Stroke Cerebrovasc Dis2018; 27: e20–e3.
32.
DeKoninckPLPijnenborgJMvan ZutphenSWArnoldusEP. Postpartum stroke, a diagnostic challenge. Am J Emerg Med2008; 26: 843. e34.
33.
RonningOMDahlABakkeSJHussainAIDeilkasE. Stroke in the puerperium treated with intra-arterial rt-PA. J Neurol Neurosurg Psychiatr2010; 81: 585–586.
34.
JohnsonDMKramerDCCohenERochonMRosnerMWeinbergerJ. Thrombolytic therapy for acute stroke in late pregnancy with intra-arterial recombinant tissue plasminogen activator. Stroke2005; 36: e53–5.
35.
Mantoan RitterLSchulerAGangopadhyayRet al.Successful thrombolysis of stroke with intravenous alteplase in the third trimester of pregnancy. J Neurol2014; 261: 632–634.
36.
RitchieJLokmanMPanikkarJ. Thrombolysis for stroke in pregnancy at 39 weeks gestation with a subsequent normal delivery. BMJ Case Rep2015; 2015: pii. bcr2015209563.
37.
AkazawaMNishidaM. Thrombolysis with intravenous recombinant tissue plasminogen activator during early postpartum period: a review of the literature. Acta Obstet Gynecol Scand2017; 96: 529–535.
38.
BhogalPAguilarMAlMatterMKarckUBaznerHHenkesH. Mechanical thrombectomy in pregnancy: report of 2 cases and review of the literature. Interv Neurol2017; 6: 49–56.
39.
AaronSShyamkumarNKAlexanderSet al.Mechanical thrombectomy for acute ischemic stroke in pregnancy using the penumbra system. Ann Indian Acad Neurol2016; 19: 261–263.
40.
TateJBushnellC. Pregnancy and stroke risk in women. Women's health (Lond)2011; 7: 363–374.
41.
TurrentineMABraemsGRamirezMM. Use of thrombolytics for the treatment of thromboembolic disease during pregnancy. Obstet Gynecol Surv1995; 50: 534–541.
42.
MurugappanACoplinWMAl-SadatANet al.Thrombolytic therapy of acute ischemic stroke during pregnancy. Neurology2006; 66: 768–770.
43.
GartmanEJ. The use of thrombolytic therapy in pregnancy. Obstet Med2013; 6: 105–111.
44.
SimolkeGACoxSMCunninghamFG. Cerebrovascular accidents complicating pregnancy and the puerperium. Obstet Gynecol1991; 78: 37–42.
45.
LiangCCChangSDLaiSLHsiehCCChuehHYLeeTH. Stroke complicating pregnancy and the puerperium. Eur J Neurol2006; 13: 1256–1260.
46.
KittnerSJSternBJFeeserBRet al.Pregnancy and the risk of stroke. N Engl J Med1996; 335: 768–774.
47.
BatemanBTSchumacherHCBushnellCDet al.Intracerebral hemorrhage in pregnancy: frequency, risk factors, and outcome. Neurology2006; 67: 424–429.
48.
LiuXJWangSZhaoYLet al.Risk of cerebral arteriovenous malformation rupture during pregnancy and puerperium. Neurology2014; 82: 1798–1803.
49.
PorrasJLYangWPhiladelphiaEet al.Hemorrhage risk of brain arteriovenous malformations during pregnancy and puerperium in a North American cohort. Stroke2017; 48: 1507–1513.
50.
LeffertLRDuboisHMButwickAJCarvalhoBHouleTTLandauR. Neuraxial anesthesia in obstetric patients receiving thromboprophylaxis with unfractionated or low-molecular-weight heparin: a systematic review of spinal epidural hematoma. Anesth Analg2017; 125: 223–231.
51.
HebertDLindsayMPMcIntyreAet al.Canadian stroke best practice recommendations: Stroke rehabilitation practice guidelines, update 2015. Int J Stroke2016; 11: 459–484.
52.
YoshimatsuJIkedaTKatsuragiSet al.Factors contributing to mortality and morbidity in pregnancy-associated intracerebral hemorrhage in Japan. J Obstet Gynaecol Res2014; 40: 1267–1273.
53.
YoshitaniKInatomiYKuwajimaKOhnishiY. Anesthetic management of pregnant women with stroke. Neurol Med Chir2013; 53: 537–540.
54.
LanskaDJKryscioRJ. Risk factors for peripartum and postpartum stroke and intracranial venous thrombosis. Stroke2000; 31: 1274–82.
55.
WitlinAGMattarFSibaiBM. Postpartum stroke: a twenty-year experience. Am J Obstet Gynecol2000; 183: 83–88.
56.
KamelHNaviBBSriramNHovsepianDADevereuxRBElkindMS. Risk of a thrombotic event after the 6-week postpartum period. N Engl J Med2014; 370: 1307–1315.
57.
TangCHWuCSLeeTHet al.Preeclampsia-eclampsia and the risk of stroke among peripartum in Taiwan. Stroke2009; 40: 1162–1168.
58.
MillerECYaghiSBoehmeAKWilleyJZElkindMSMarshallRS. Mechanisms and outcomes of stroke during pregnancy and the postpartum period: A cross-sectional study. Neurol Clin Pract2016; 6: 29–39.
59.
LeffertLRClancyCRBatemanBTet al.Patient characteristics and outcomes after hemorrhagic stroke in pregnancy. Circ Cardiovasc Qual Outcomes2015; 8: S170–8.
60.
MillerECGatollariHJTooGet al.Risk of pregnancy-associated stroke across age groups in New York State. JAMA Neurol2016; 73: 1461–1467.
61.
YoshidaKTakahashiJCTakenobuYSuzukiNOgawaAMiyamotoS. Strokes associated with pregnancy and puerperium: a nationwide study by the Japan Stroke Society. Stroke2017; 48: 276–282.
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