STROKE

&
PREGNANCY
By Judith Barnaby, Stroke CNS
Reviewed by Dr. Bayer, Stroke
Neurologist, St. Michaels Hospital

Learning Objectives
To identify pertinent research statistics that pertain to

the subject matter

To review physiological changes associated with
pregnancy
To recognize the risk factors for pregnancy as it
relates to stroke
To discuss the management therapies
To review a case study (stroke and pregnancy): Case
analysis and application of theory
To review cerebral venous sinus thrombosis

Statistics
Stroke is the second leading cause of death of

women in Canada and the United States

According to Jaigobin & Silver, there is a higher
incidence of stroke in young women than in men
between the ages of 15 and 30 to 35 years. (Stroke
related pregnancy)
Pregnancy-related stroke is, a rare, but potentially a
devastating event
Washington study: 0.7% risk of cerebral infarction
during pregnancy and 8.75 during the post-partum
period. 2.5% risk of intracerebral bleed during
pregnancy and 28.3% post-partum

Statistics Contd:
Pregnancy related stroke in the UK: 11 to 26 deliveries per 100

000
Approx. 8% to 15% of pregnancy related stroke victims die
C-Section deliveries (3 to 12 times higher risk) than vaginal
deliveries
A study in the UK identified that thromboembolism was the
leading cause of maternal death (a study in the US: 5,723 cases
out of 8,918 cases were venous thrombosis in nature)
Most common cause of cerebral infarction: eclampsia and
preeclampsia.
Most common cause of intracerebral bleed: arterial aneurysm
and Arteriovenous malformation (AVM)

Physiological Changes Associated

with Pregnancy
Hypercoagulable state is characteristic of

pregnancy
1. Marked increase in fibrinogen and factor VIII
(8). Factors VII (7), IX, X and XII are also
increased but to a lesser extend. Fibrinolytic
activity is depressed during pregnancy and
labour
2. Deep Vein Thrombosis (DVT) is a common
complication (1 to 2%; vaginal delivery and 2
to 10% for C-section delivery). Pulmonary
embolism is a potential complication

Risk Factors for Pregnancy Related

Stroke
Hematological Disorders
Preeclampsia
Gestational Diabetes
Post-Partum Period
Race
Age older than 35 y.o.
Other

Hematological Disorders
Anemia may result from blood loss that

results in cerebral hypoperfusion

Thrombocytopenia (low platelet count)
Sickle Cell Disease

Pre-eclampsia
Pre-eclampsia is a form of pregnancy-associated

high blood pressure and protein in the mothers urine

Increase risk associated with 1st pregnancy, adv.
maternal age, black heritage and past hx: DM &
HBP)
Occurs in about 5 to 7 % of all pregnancies
Some research suggests that women who develop
pre-eclampsia have a 60 per cent > risk of nonpregnancy-related ischemic stroke
1 out of 200 women who have preeclampsia, blood
pressure becomes high enough to have seizures; this
condition is called eclampsia

Gestational Diabetes
Gestational Diabetes is the inability of the

body to process carbohydrates during

pregnancy.
All pregnant women should be screened for
gestational diabetes during their pregnancy
In many cases blood glucose levels return
back to the pre-pregnancy state after delivery
Diabetes is a risk factor for stroke

Post-Partum Period
In thromboembolic disease blood clots form in the

vessels.
This risk of developing thromboembolic disease is
increased for about 6 to 8 weeks after delivery.
Most complications results from injuries that occur
during delivery.
The risk is greater after a cesarean section than after
vaginal delivery
In one study (NEJM) the extremely high relative risk
of stroke during the postpartum period is likely the
result of a decrease in blood volume or the rapid
changes in hormonal status or the hemodynamic,
coagulative or vessel-wall changes

Race
Black women had the highest risk of stroke

(52.5 per 100,000 deliveries)

Hispanic women (26.1 per 100,000 deliveries)
White women (31.7 per 100,000 deliveries)

Age > 35 y.o.

The risk of stroke generally increases with

age
The risk increased dramatically among
women aged 35 to 39 years (58.1 per 100,
000 deliveries)
The highest risk among women aged 40
years and older (90.5 per 100,000 deliveries)

Other
Cocaine abuse
Smoking
Hyperemesis
Transfusion
Cardiac

Management
Venous Thrombosis
Pregnant women: LMWH or unfractionated

heparin for DVT. Coumadin is usually

contraindicated.
Post-Partum women: LMWH for 7 to 10 days
may be followed by Coumadin for 3 to 6
months.

Management contd:
Stroke and Pregnancy
Antiplatelet therapy
Heparin therapy
Thrombolysis (the safety of thrombolysis in

acute ischemic stroke during pregnancy

remains unproven)

Risk of Stroke Recurrence

The overall risk is small
Approximate risk of recurrent stroke of 1%= in

the following 12 months and 2.3% within 5

years

Case Study
See hand-out

Cerebral Venous Sinus Thrombosis

Is a rare from of thrombosis (blood clot)
Affecting the dural venous sinuses which

drains blood from the brain

Symptoms include: headaches, any of the
symptoms of stroke, seizures, abnormal
vision, and raised intracranial pressure
Risk factors: Pregnancy, thrombophilia, birth
control pill, chronic inflammatory diseases
Treatment: anticoagulants medications and/or
tPa

Final Message
Although uncommon, the development of

stroke and pregnancy should be managed in

a specialized setting that can incorporate the
expertise of obstetrics, neurology, neuroradiology and rehabilitation services