31 YRS OLD Gravida 3 Para 2 presented with confusion and unable to feel foetal movements at 36 weeks gestation. Urgent MRI of head demonstrated hyper acute infarct in the posterior limb of the left internal capsule.
INTRODUCTION
Ischemic stroke is a rare occurrence in pregnancy and Physicians can be faced with difficult therapeutic decisions.
Background:
HW had been attending ANC for gestational diabetes treated with Insulin and Metformin.
Antenatal screening normal ; morphology scan was normal. BMI 42 at booking
She was normotensive throughout pregnancy and during current episode.
Previous pregnancies complicated with GDM - diet controlled, both delivered vaginally at 42 weeks (9 and 10 lbs) ;
No symptoms prior to this admission. No drug allergies and not a lifetime smoker.
Patient was admitted to HDU and later to stroke unit managed by MDT - Physician , Obstetric Physician , Obstetrician , Anaesthetist , Physio – Occupational therapist , social worker.
Started on Aspirin 100 mgm OD Clopidogrel 75 mgm PO OD and Atorvastatin 10mgm PO OD.
Patient received Clopidogrel until 1 week before IOL with Foleys catheter followed by AROM / syntocinon . Received epidural and delivered vaginally
Live female infant of 4130 grams . No neonatal concerns. MDT care by stroke team.
Discharged home on aspirin , atorvastatin and regular follow up by stroke team.
Discussion:
Clopidogrel has not been proven to be safe in pregnancy- it does cross the placenta. But our patient stabilised and improved well on this treatment and did not have any bleeding episodes during delivery or post partum when it was stopped 1 week before induction of labour. Baby did not have any undue bleeding incident.
Pregnancy is still considered a relative contraindication to thrombolytic treatment although there are no reports on rTPA (recombinant tissue plasminogen activator) being able to cross human placenta.