A review of stroke in pregnancy: incidence, investigations and management

Abstract

Key content The incidence of stroke in young and middle‐aged adults is increasing, with pregnancy‐related strokes occurring in 30 in 100 000 pregnancies; strokes are three times more common among pregnant than among nonpregnant individuals aged 15–44 years. The investigation and management of stroke is changing because of the time‐sensitive benefits of thrombolysis and thrombectomy in the acute management of ischaemic stroke. The approach to clinical assessment and investigation of a pregnant woman presenting with suspected stroke is not different from that of a nonpregnant patient: timely brain imaging and intervention is important to optimise long‐term outcome, and further investigations should be directed towards determining the aetiology and risk factors of stroke. The ‘time is brain’ approach to treatment is imperative: thrombolysis with recombinant tissue plasminogen activator administered within 4.5 hours of stroke onset significantly improves overall outcome. Mechanical thrombectomy is appropriate in only 10% of patients with acute ischaemic stroke, but has been shown to improve outcome if performed within 6 hours of onset and can be performed up to 24 hours in highly selected cases. Trials have largely excluded pregnant women, although thrombolysis can be performed to treat moderate to severe stroke in pregnancy if the benefits outweigh the risk of uterine bleeding. As recurrent strokes occur in 25–30% of cases, identification of risk factors for stroke in a young woman is important as this will direct the approach to secondary prevention and management in future pregnancies. Learning objectives To understand the clinical presentation, aetiology and differential diagnosis of stroke in pregnancy. To know the current recommendations for investigation and management of acute stroke and how they apply to pregnancy. To understand the secondary prevention of stroke and the safety of these strategies in pregnancy. To recognise of the importance of multidisciplinary input in the management of pregnancy and delivery in women with stroke. Ethical issues There have been no published trials in pregnant women. How should the maternal and fetal risks be balanced while investigating and treating acute stroke?