Medical problems in pregnancy

Editor – As a middle-grade doctor I found this article very useful.¹

As commented by the authors, women are delaying childbirth until later in life.¹ Older women are more likely to have a medical disorder like hypertension, hyperlipidemia or diabetes mellitus, which are known risk factors for stroke.

Stroke in pregnancy has not been covered in this article; hence we are discussing this topic.

Stroke in pregnancy is relatively rare, but there is a three-fold increase in stroke incidence compared with non-pregnant women.² Acute stroke during pregnancy is a serious and stressful event, not only for the patient and family members but also for healthcare professionals.

The authors have rightly included cerebral venous sinus thrombosis, pre-eclampsia, eclampsia, and reversible vasoconstriction syndromes as the possible differential diagnosis of stroke in pregnancy.¹ Other causes of stroke are amniotic fluid embolism, postpartum angiopathy and postpartum cardiomyopathy.

In our experience the three common examinations that are not routinely performed are fundoscopy, blood pressure measurement in both arms and urine analysis for proteinuria.

MRI of the brain without contrast is the preferred imaging option in pregnancy. Time-of-flight MR angiography, which does not require contrast administration, can be used to evaluate the cerebral vasculature. CT brain may be performed if facility for MRI imaging is not available.⁵

Thrombolysis data are lacking as pregnant women were excluded from the clinical trials that validate rt-PA (recombinant tissue plasminogen-activator) in acute ischaemic stroke. Our knowledge about its use in this condition is based on case reports or case series.³ Data from case studies has shown that thrombolysis is effective in ischemic strokes with a relative low risk to mother and foetus.³

Thrombolysis for ischaemic strokes should be considered after discussion with the obstetric team and the patient. The risks and benefits should be explained to the patient before administrating systemic thrombolysis. Thrombolytic therapy complications include pre-term labour, placental abruption, foetal death, post-partum haemorrhage and possible teratogenicity.³ Acute stroke treatment decision-making is a complex process that must be performed quickly.⁴

With obstetric back-up, intravenous rt-PA should be administered followed by ‘rescue’ mechanical thrombectomy in situations where no clinical improvement is seen.⁴

In pregnant patients with malignant middle cerebral artery infarction syndrome and impending herniation, early decompressive craniotomy can reduce mortality and increase the likelihood of favourable outcome.

Haemorrhagic stroke also affects pregnant women. Non-contrast CT brain is the imaging modality of choice if SAH is suspected. Lumbar puncture to evaluate for xanthochromia can be useful if the CT shows no detectable subarachnoid blood, yet the suspicion for SAH is very high. Studies have suggested that surgical management of ruptured aneurysms during pregnancy is associated with significantly lower maternal and foetal mortality.

Last but not the least, there is a potential for medico-legal issues with all medical problems in pregnancy, hence the importance of clear documentation in medical notes of all discussions and the rationale for choosing a particular investigation or treatment.

Conflicts of interest

The authors have no conflict of interest to declare.