Stroke During Pregnancy: Guidelines Knowledge Check

Gerard Kiernan, MD, FAAFP, FHMEmergency Medicine, Family Medicine, Guideline Knowledge Check, Nurse Practitioner

Stroke During Pregnancy Clinical Guideline Knowledge Check

Stroke During Pregnancy

Clinical Guideline Knowledge Check

Let's look at the current stroke during pregnancy guidelines. The 2018 AHA Ischemic Stroke Guidelines have replaced the familiar list of “relative contraindications to IV alteplase” with “additional recommendations for IV alteplase.”  So, what is recommended for treating ischemic stroke during pregnancy – one of the previous relative contraindications to fibrinolysis?

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Today’s Guideline Knowledge Check question comes from the desk of Med-Challenger Emergency Medicine Editor-in-Chief, Andrea Eberly, MD, FAAEM.

Are you following the most current guidelines for Stroke During Pregnancy?

Stroke During Pregnancy Case:

A 42-year-old, previously healthy, and obviously pregnant female is transported to the hospital with a new onset gaze palsy, difficulty with speech, unilateral weakness/numbness, somnolence, and confusion.

These symptoms began suddenly about 40 minutes ago while she was having a disagreement with her employer about taking time off after giving birth.

Her initial National Institute of Health Stroke Scale (NIHSS) score is determined to be 10.

A non-contrast CT scan indicates ischemic stroke without hemorrhagic complications; a bedside ultrasound shows a viable fetus of about 7 months gestational age.

A quick review shows that the patient meets the non-pregnancy related inclusion criteria for IV alteplase and does NOT meet any of the non-pregnancy related exclusion criteria.

NIHSS calculation tool: NIH Stroke Scale/Score (NIHSS)

What do the 2018 AHA guidelines recommend with regards to thrombolysis in this patient with stroke during pregnancy?

Answer Options:

Give intravenous alteplase to a pregnant patient with ischemic stroke as if the patient were not pregnant as long as the anticipated delivery date is ≥ 2 weeks from the onset of the stroke and no other contraindications exist.

Consider intravenous alteplase in a pregnant patient with a moderate to severe stroke because in this group, the potential benefits may outweigh the potential risks of a uterine bleed.

Intravenous alteplase is contraindicated and emergency C-section followed by an endovascular procedure is recommended in a pregnant patient in her third trimester due to the significant risk of a fetal cerebral bleed.

Do not give intravenous alteplase to a pregnant patient with NIHSS score < 12 because the bleeding risk to the mother and the combined teratogenic and bleeding risks to the fetus outweigh the anticipated modest gain in disability score for the mother.

See the Answer:

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About the Author:

Andrea Eberly, MD, FAAEM graduated from the David Geffen Medical School of Los Angeles (UCLA) and completed her residency in Emergency Medicine at the University Medical Center, Tucson, Arizona. After working as an attending physician in Tucson, she followed a recruiting call to the island of Guam, where she served in various roles, including as the director of the emergency department, the EMS Medical Director of Guam, and the Director of the 911 Call System. She has maintained her emergency medicine board certification through three cycles of American Board of Emergency Medicine Board Exams (last in 2014), all three with the help of Med-Challenger.