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16-Strock In Pregnancy > TOG > Flashcards

TOG Flashcards

1
Q

What is the incidence of stroke in pregnancy?

A

📌30 / 100,000
(3 times more at the same age )
📌 90 % occur peripartum or in 6 weeks after delivery

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2
Q

What is the greatest cause of maternal death from stroke?
What is the mortality rate?

A

📌Mortality rate : 8- 20 %
📌Greatest cause of death from stroke Is ICH

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3
Q

What is the aetiology of stroke in pregnancy?

A

Ischemic / haemorrhage / venous thrombosis: have a similar contribution
( general population ischemic is the major cause)
🔴 fatality rate & disability are higher with hemorrhagic stroke

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4
Q

What is the recurrence rate of stroke in subsequent pregnancies?

A

0 - 1.8 %
🚩 with concurrent thrombophilia 👉 20%

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5
Q

What are the independent risk factors for stroke in pregnancy?

A

1- age > 35 y
2- migraine
3- gestational diabetes ( MAXIMUM RISK)
4- preeclampsia / eclampsia
5- pre existing hypertension

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6
Q

What are pregnancy specific conditions that contribute to stroke ?

A

🚩Hypercoagulability :
1- OHSS
2- hyperemesis gravidarum
3- preeclampsia ( ischemic/ hemorrhagic)
🚩Prothrombin conditions: ( ischemic)
1- APL 2- SSD
3- thrombocytopenia purpura
4- mechanical heart valve
5- hemolytic uremic syn
6- cardiomyopathy
🚩 amniotic fluid embolism ( rare)

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7
Q

What are the symptoms of the stroke that the patient may presented with?

A

ONLY 40 % presenting with TYPICAL symptoms:
1- unilateral numbness
2- weakness of face led arm
3- dysphasia
4- hemianopia
5- ataxia / dysarthria

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8
Q

How to recognize symptoms of stroke based on FAST campaign?

A

1- face dropping
2- arm weakness
3- speech difficulties
4- time to call

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9
Q

Any seizure after 20 w of pregnancy & up to 2 w postnatally is caused by….

A

Eclampsia

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10
Q

What are the features suggestive of ICH ( sub arachnoid hemorrhage)?

A

Hypertension + bradycardia 👉 suggest ICH rather than a stroke
🚩[ Hypertension is a consequence rather than a causative factor]

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11
Q

What are the scales used in assessing a patient with a stroke ?

A

1- NIHSS
2- MODIFIED RANKIN 0-6 ( based on disability)

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12
Q

What is the most accurate imaging assessment in a patient with suspected stroke?

A

Combination of CT perfusion + CT angiogram
🚩Ct perfusion⬆️specificity ischemia
🚩Ct angiogram:⬆️specificity arterial stenosis

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13
Q

What is safer imaging method in a pregnant woman suspected of stroke Ct angiogram or Ct perfusion

A

Ct angiogram
Cause less radiation than Ct perfusion

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14
Q

What is the first investigation that should be done on arrival to hospital in a pregnant woman with stroke?

A

Non contrast CT
Radiation exposure 0,5 - 1 mGy
❤ fetal radiation dose of less than 100 mGy is not associated with adverse effects on human being

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15
Q

What is the preferred first line imaging modality in pregnancy with stroke?

A

MRI
no exposure to radiation
No harmful effects shown at 1,5 T or less
* theoretical fetal ear damage due to acoustic noise level

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16
Q

After imaging the brain what further investigations should be done in a pregnant woman with stroke?
What is the first line?

A

1- 12 h ECG
2- 24 h cardiac holter
*FIRST LINE: TRANSTHORACIC ECHO
4- blood glucose:( exclude hypoglycemia)
5- CBC - troponin - coagulation profile- LFTs - urea - electrolytes- lipid profile
6- carotid & lower limb Doppler
🚩 thrombophilia screening Not recommended in pregnancy

17
Q

What is the management of the stroke in pregnancy?

A

IV thrombolysis in stroke care unit
🚩rt-PA ( recombinant tissue plasminogen activator) WITHIN 4,5h
Of stroke onset
🚩risk of hemorrhage: 2-6 %
🚩does not cross the placenta
🚩pregnancy is a relative contraindication : ICH / systemic bleeding/ anaphylaxis
🚩no studies : on its safety in breastfeeding

18
Q

What is the absolute contraindication of rt-PA ?

A

ICH

19
Q

What is post stroke thrombolysis care?

A
  • bedrest 24 h
  • no arterial or central line or nasogastric tube 24h
  • NO ASPIRIN/ CLOPIDOGREL / ANTICOAGULANTS 24h
    🚩 repeat Ct 24-36h
20
Q

What is the management of intracerebral hemorrhage?

A

1- hemostasis
2- correlation of coagulopathy & thrombocytopenia
3- aggressive BP control < 140
4- SHOULD have intermittent pneumatic compression from the day of admission

21
Q

What is the main cause of posterior reversible encephalopathy syndrome ( PRES)?

A

PRES: mainly associated with Preeclampsia & eclampsia
Coexistence with renal disease

22
Q

How are patients with PRES presented?

A

Rapid onset of: headache + seizures + altered consciousness + visual disturbance ( acute hypertension)

23
Q

On MRI : what is the commonest areas in involved in patient with PRES?

A

Parieto - occipital

24
Q

What is the management for secondary prevention of the stroke?

A

🚩recurrent strokes account for 25- 30 of all strokes
1- control BP
2- ASPIRIN: within 24-48h ( for patients receiving thrombolysis aspirin should be delayed 24 h)
3- CLOPIDOGREL + ASPIRIN: within 24h continued 21 days (in ischemic stroke )
4- atrial fibrillation: anticoagulant within 4-14 days of the onset of neurological symptoms (LMWH)

25
Q

In secondary prevention of stroke how CLOPIDOGREL administration is classified in pregnancy?

A

Category B
*Should be stopped 7-10 days before scheduled delivery
* if spontaneous labour occurs: avoid neuroaxial anaesthesia

26
Q

What is the preference for the mode of delivery in pregnant women with a previous stroke in pregnancy?

A

Vaginal birth is safe
*Early epidural: to reduce the fluctuation in BP
* shortening 2nd stage: elective operative delivery

27
Q

What is the postpartum management in women with previous stroke in pregnancy?

A

🚩Postpartum period is the highest risk period for stroke & venous thrombosis
📌continue LMWH 6 W
📌 warfarin +LMWH +aspirin: are safe during breastfeeding
📌 thrombophilia screening: arranged 6w postnatally

28
Q

How to advice women with previous stroke in pregnancy about contraception?

A

Non hormonal contraceptives
Combined OC +POP : are contraindicated
POP : increase risk of stroke

29
Q

What is the pre conceptual care for women with previous stroke?

A

1-STOP : statins + warfarin + clopidogryl
2- control BP
3- high risk of thrombosis 👉LMWH

16-Strock In Pregnancy (1 decks)

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