Cerebrovascular Complications of Pregnancy

Background

• Cerebrovascular complications of pregnancy may occur during pregnancy, labor, or post partum. Cerebrovascular complications include stroke, preeclampsia/eclampsia, cerebral venous thrombosis (CVT), posterior reversible encephalopathy syndrome (PRES), and postpartum reversible cerebral vasoconstriction syndrome (RCVS).
• Incidence of pregnancy-related stroke is approximately 34 strokes per 100,000 deliveries, however, incidence is reported to vary by ethnicity.
• Reported prevalence of preeclampsia in United States is 3.8%.
• Physiological changes occurring during pregnancy as well as preexisting disease increase risk of cerebrovascular complications.
• Highest risk of pregnancy-related stroke occurs from third trimester through 6 weeks post partum. Specific risk factors associated with cerebrovascular complications include
  • hypertensive disorders of pregnancy, such as preeclampsia/eclampsia, for pregnancy-related stroke and PRES
  • hypertension for preeclampsia/eclampsia
  • postpartum medications and hormonal changes for RCVS
• Complete recovery or mild disability (modified Rankin Scale [mRS] score 0-2) reported in 65%-82% of women with cerebrovascular complications associated with pregnancy or postpartum period.
• Increased risk of recurrence is associated with postpartum period in women with arterial ischemic stroke.

Evaluation

• Suspect pregnancy-related stroke if sudden onset of headache or focal neurologic deficit, such as difficulty with speech or hemiparesis.
  • Consider diagnostic options with focus on limiting risk of radiation and contrast exposure to fetus, however, diagnostic imaging should not be withheld when indicated and potential benefits should outweigh risks (Weak recommendation).
  • Confirm diagnosis using magnetic resonance imaging (MRI) with diffusion-weighted imaging (DWI) or noncontrast computed tomography (CT) of head if MRI is not readily available or if contraindication to MRI (see Stroke [acute management] for details).
  • If IV contrast is contraindicated, consider carotid ultrasound or transcranial Doppler imaging for assessment of intra- and extracranial cerebral vasculature without contrast.
• Suspect preeclampsia in pregnant women after 20 weeks gestation and post partum with hypertension (blood pressure [BP] ≥ 140/90 mm Hg)
  • Perform urinalysis to assess for proteinuria (> 300 mg/24 hours) (Strong recommendation).
    • Urinary dipstick testing is recommended for screening if suspicion of preeclampsia is low.
    • Definitive testing with urinary protein:creatinine ratio or 24-hour urine collection is recommended if urinary dipstick proteinuria is ≥ 1+ in women with either of the following (Strong recommendation)
      • hypertension and rising blood pressure
      • normal blood pressure, but symptoms or signs suggestive of preeclampsia
  • If no proteinuria, a diagnosis of preeclampsia is confirmed with thrombocytopenia, elevated serum liver transaminases, new renal insufficiency, pulmonary edema, and/or new-onset cerebral or visual disturbances (see Hypertensive disorders of pregnancy for details).
  • Eclampsia may present with any symptoms/signs of preeclampsia plus seizures and manifestations of cerebral edema and/or encephalopathy.
• Other testing
  • should include
    • electroencephalogram (EEG) in women with preeclampsia/eclampsia or PRES
    • fetal testing/monitoring in women with preeclampsia/eclampsia
    • blood tests, such as complete blood count (CBC) and chemistry profile, in women with stroke, preeclampsia, or CVT
  • may include
    • electrocardiography (ECG) in women with stroke
    • echocardiography in women with suspected patent foramen ovale (PVO), embolic stroke, and/or coronary artery disease
• Suspect postpartum RCVS in women with thunderclap headache with or without focal neurologic signs and symptoms (see Reversible cerebral vasoconstriction syndrome (RCVS) for details).

Management

• Individualize treatment is based upon specific complication and analysis of potential risk and benefit.
• Management of preeclampsia/eclampsia
  • Delivery
    • Indications for delivery include
      • preeclampsia and mature fetus (gestational age ≥ 37 weeks) (Strong recommendation)
      • gestational age ≥ 34 weeks and maternal or fetal distress (Strong recommendation)
      • severe preeclampsia or hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome (delivery recommended soon after maternal stabilization for women who are > 34 weeks gestation or have unstable maternal or fetal conditions regardless of gestational age [Strong recommendation])
    • Consider vaginal delivery unless cesarean section is indicated for other obstetric indications (Weak recommendation).
  • Indications for expectant management include
    • superimposed preeclampsia without severe features and stable maternal and fetal conditions (consider expectant management until 37 weeks 7 days gestation) (Weak recommendation)
    • nonsevere preeclampsia at 24-33 weeks 6 days gestation (if in perinatal center capable of caring for very preterm infant) (Weak recommendation)
  • Antihypertensive therapy
    • Treat severe hypertension (diastolic BP ≥ 110 mm Hg or systolic BP ≥ 160 mm Hg) with safe antihypertensive medications (Strong recommendation), such as
      • methyldopa 0.5-3 g/day orally in 2-3 divided doses
      • labetalol 200-2,400 mg/day orally in 2-3 divided doses
      • nifedipine 30-120 mg/day orally (slow-release preparation)
    • Consider treatment of moderate hypertension (diastolic BP 100-109 mm Hg or systolic BP 150-159 mm Hg) with safe antihypertensive medications due to risk of complications (Strong recommendation).
    • Do not treat hypertension in women with mild gestational hypertension or preeclampsia with persistent diastolic BP < 110 mm Hg or systolic BP 160 mm Hg ((Weak recommendation); see Hypertensive disorders of pregnancy for details).
  • Use magnesium sulfate (standard dose 4-6 g IV loading dose followed by maintenance dose of 1-2 g/hour for ≥ 24 hours) as first-line treatment for women with preeclampsia/eclampsia (Strong recommendation).
  • Corticosteroids
    • Use corticosteroids for severe preeclampsia in women receiving expectant management at ≤ 34 weeks gestation for fetal lung maturity benefit (Strong recommendation).
    • Consider corticosteroids and deferring delivery for 48 hours in women with severe preeclampsia if maternal and fetal conditions remain stable (Weak recommendation).
• Management of ischemic stroke
  • Consider endovascular therapy or mechanical thrombectomy in similar circumstances as nonpregnant patients making sure to limit exposure of fetus to scattered radiation during angiography; reperfusion therapy does not appear to increase risk of in-hospital death, serious or life-threatening hemorrhage, or other complications in pregnant or postpartum women.
  • Consider IV thrombolysis for treatment of potentially disabling stroke in pregnant or postpartum women.
  • Consider low-dose aspirin (50-150 mg/day orally) (after first trimester) or low-molecular-weight heparin (LMWH) or unfractionated heparin for prophylaxis following ischemic stroke (Weak recommendation).
• Management of CVT
  • Use full-dose low-molecular-weight heparin (LMWH) throughout pregnancy to treat CVT; continue for ≥ 6 weeks post partum (minimum therapy duration 6 months) (Strong recommendation).
  • Consider vitamin K antagonists during pregnancy, especially if provoked CVT; continue for ≥ 6 weeks post partum (minimum therapy duration 6 months) (Weak recommendation).
  • Consider indefinite anticoagulation (target INR 2-3) in women with recurrent CVT, venous thromboembolism (VTE) after CVT, or first CVT with severe thrombophilia (Weak recommendation).
• For prevention of preeclampsia
  • Low-dose aspirin (from 12 weeks gestation until delivery) recommended for women with chronic primary or secondary hypertension or history of pregnancy-related hypertension (Strong recommendation).
  • Consider calcium supplementation in women with low dietary intake of calcium (< 600 mg/day) (Strong recommendation).
• Consider secondary prevention with anticoagulant or antiplatelet therapy in women with history of pregnancy-related stroke (Weak recommendation).