Stroke, the sudden loss of neurological function due to neuronal injury of a vascular cause, is a leading cause of disability in adults. When stroke occurs during pregnancy, the impact on the mother, child and families can be devastating. A recent systematic review and meta-analysis funded by Heart & Stroke showed that stroke affects 30/100,000 pregnancies, roughly 3 times higher than the risk in young adults. Several aspects of pregnancy can increase the risk of stroke including: hypertensive disorders of pregnancy (gestational hypertension, preeclampsia with or without chronic hypertension, eclampsia, HELLP syndrome [hemolysis, elevated liver enzymes and low platelets syndrome]) and their complications: hematologic and prothrombotic changes, particularly in the third trimester and post-partum periods; hyperemesis resulting in hemoconcentration; and changes to cerebral vasculature (for example, reversible cerebral vasoconstriction syndrome (RCVS), as well as growth of existing arteriovenous malformations).

Given this etiological variability, the practical limitations to clinical research in pregnant patients with stroke, and the rarity of events, it is not surprising that there is limited literature to guide important management decisions. Yet, stroke is sufficiently common that most specialists providing either obstetrical or stroke care encounter either women with a past stroke wanting to get pregnant, or women who develop a stroke during or just after a pregnancy. Thus, there is a need for a rational approach to management decisions, based on the best available literature and guided by expert consensus.

Goal: To provide guidance on the management of stroke in pregnancy based on a critical appraisal of current evidence on obstetrical and stroke management informed by expert review and appraisal.

Scope: A set of two consensus statements have been developed based on the process above, focused on the unique aspects of pregnancy-related stroke. Part One addresses secondary prevention for women who have a history of stroke and are pregnant or planning to become pregnant; Part Two addresses treatment and management of a woman who experiences a stroke while pregnant or in the early postpartum period.

Most consensus statements within these documents are applicable to both ischemic and hemorrhagic stroke. In cases where the statements are applicable to one type or the other, these will be explicitly stated.

This set of consensus statements seeks to organize an approach and apply existing evidence to this specific subset of stroke patients (those pregnant) and this specific subset of pregnant patients (those with acute or previous stroke).

Target audience for this consensus statement is health care professionals that manage stroke and/or pregnancy, including maternal-fetal medicine specialists, obstetricians, family physicians, obstetrical medicine specialists, obstetrical anesthetists, internists, neurologists and critical care specialists, emergency medicine, radiologists, nursing professionals from neurological, obstetrical and critical care backgrounds, and stroke rehabilitation specialists

Consensus Statement 2017 Module contents +-

Prevention of Stroke in Pregnancy – 2017

This consensus statement is focused on the issues of stroke prevention encountered by a woman who has had a stroke in the past and is now planning to become pregnant, is currently pregnant, or who has had a stroke in pregnancy but is beyond the hyperacute phase. We first address general management considerations from preconception counseling to pregnancy and post-partum including breastfeeding (Part 1). We then review management considerations for commonly used secondary prevention strategies (Part 2), including antithrombotic medications (both antiplatelets and anticoagulants), blood pressure management, lipid management and diabetes care. Finally, we address some of the more common specific causes of stroke that affect young women of childbearing age and pregnancy (Part 3) including cardioembolic stroke, cerebral venous sinus thrombosis and cerebral artery dissection.

Prevention and Pregnancy Consensus Statement 2017 module contents

Publication of the Secondary Prevention of Stroke during Pregnancy Consensus statement in the International Journal of Stroke

Citing the Secondary Prevention of Stroke during Pregnancy 2017 Module

Richard H Swartz (Co-First Author), Noor Niyar N. Ladhani (Co-First Author), Norine Foley, Kara Nerenberg, Simerpreet Bal, Jon Barrett, Cheryl Bushnell, Wee-Shian Chan, Radha Chari, Dariush Dowlatshahi, Meryem El Amrani, Shital Gandhi, Gord Gubitz, Michael D Hill, Andra James, Thomas Jeerakathil, Albert Jin, Adam Kirton, Sylvain Lanthier, Andrea Lausman, Lisa Rae Leffert Jennifer Mandzia, Bijoy Menon, Aleksandra Pikula, Alexandre Poppe, Jayson Potts, Joel Ray, Gustavo Saposnik, Mukul Sharma, Eric E Smith, Sanjit Bhogal, Elisabeth Smitko, and M Patrice Lindsay (Senior and Corresponding Author), on behalf of the Heart and Stroke Foundation Canadian Stroke Best Practice Advisory Committees. In Lindsay MP, Gubitz G, Dowlatshahi D, Harrison E, and Smith EE (Editors). Canadian Stroke Best Practice Recommendations 6^th Edition: Secondary Stroke prevention during Pregnancy Consensus Statement, 2017; Ottawa, Ontario Canada: Heart and Stroke Foundation. www.strokebestpractices.ca

Stroke Foundation’s Stroke Team at strokebestpractices@heartandstroke.ca.

Prevention of Recurrent Stroke in Pregnancy

Stroke Resources