Demographic profile and evaluation of cerebrovascular accidents in pregnancy and puerperium

INTRODUCTION: Stroke in younger age groups is more common in females than males. The outcome is poor in females in terms of morbidity and mortality. There have been many studies analyzing the role of female endocrine physiology in CVA. Pregnancy, hormonal contraceptives, and hormone replacement therapy are some of the female specific risk factors which have been analyzed by many authors. Because of its physiological prothrombotic state pregnancy and puerperium are known risk factors for Thrombo embolic disorders. CVA during pregnancy and puerperium are recognized and feared complications as they account for around 12% of all maternal mortality. Since the direct causes for maternal mortality has been brought down, there is growing interest on the non-obstetric causes like stroke. Pregnancy related stroke has a wide spectrum of clinical presentation which makes it as a diagnostic and therapeutic challenge to the treating obstetrician. Development in the field of Neuroimaging helps us for early diagnosis and changed our approach towards this disorder. Here we discuss the relevant areas unique to pregnancy including the role of investigations, management and outcome. AIM OF THE STUDY: To study the demographic profile, predisposing factors, spectrum of clinical presentation, management and prognosis of Cerebro Vascular Accidents, which occur during pregnancy and puerperium. MATERIALS AND METHODS: A study of the patients with cerebrovascular accidents during pregnancy and puerperium admitted in our Institution for a period of 22 months was done. Type of study: Prospective and Retrospective Analysis. Population under study: Patients admitted in Labour ward, Intensive medical care unit and Neurology unit of Tirunelveli Medical College Hospital with cerebrovascular accidents during pregnancy or puerperium from January 2011 to October 2012. Inclusion criteria: Patients presenting with headache, altered sensorium, unifocal or multifocal seizures, neurological deficit and behavioral abnormalities during pregnancy or within six weeks of delivery. Exclusion criteria: Patients with history of trauma, seizure disorder, infections (meningitis and encephalitis) and intracranial space occupying lesions. SUMMARY: Observations obtained through our study are summarized below: • Highest incidence of stroke was noted in the 18-25 year age group with55.17%. • Maximum occurrence of CVA was noted in Primi gravida and Primipara with 43.67%. • 70% of Cerebral Vascular Accidents occurred in lower socio economic group (Class IV &V). • 71.26% of patients belong to rural background. • Incidence of CVA was higher in the postpartum period (80.45%), specifically in the second week of postpartum which was 44.82%. • 55.71% of patients with postpartum CVA had undergone LSCS. • Anemia, as a risk factor, was noted in 62.06% of patients. Second common risk factor was Hypertensive disorders which was present in 44.82%. • Most common clinical feature was headache followed by convulsions. • More than half of the patients (56%) had altered sensorium. • Generalized seizures are more common than Focal seizures. • In the present study most common cause for pregnancy related stroke was CVT accounting for 63%. • In CVT, Superior Sagittal Sinus thrombosis was the most common pathology, noted in 72.72%. • Complete recovery was noted in 68.96% of patients and PRES and Venous infarct had good prognosis. The mortality was 13.79%. Patients with ICH or Haemorrhagic infarct had high mortality. CONCLUSION: CVA is one of the serious complications of pregnancy and puerperium and it is a recognized cause for maternal mortality. It has a wide spectrum of clinical presentation. CVT is the commonest cause for pregnancy related stroke. Though hypercoagulable state of pregnancy creates the risk, it is possible to prevent CVA by timely identification and correction of risk factors. Important risk factors are anemia, preeclampsia, infection, operative procedures and dehydration. Classical symptoms of CVT are headache, convulsions and altered sensorium. Investigations should be aimed at identification of not only the diagnosis also the etiology like thrombophilias. The ideal imaging modality for CVT is MRI with MR Venography. Patients with arterial or venous infarct are treated with Heparin followed by oral anti coagulants. Of all the patients with pregnancy related CVA, patients with CVT have better prognosis except those with haemorrhagic infarct