Emergency Department Management of Stroke in Pregnant and Postpartum Patients - Stroke EXTRA Supplement (Stroke CME)

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Publication Date: December 2023 (Volume 25, Supplement 12)

CME Credits: 4 AMA PRA Category 1 Credits™ and 4 AOA Category 2-B CME credits. CME expires 12/15/2026.

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Stroke and 1 Pharmacology credits, subject to your state and institutional approval.

Authors

Peer Reviewers

Abstract

Maternal stroke contributes to a significant burden of disease in the pregnant and postpartum patient populations, with an incidence nearly 3-fold that of comparable nonpregnant cohorts. Emergency clinicians must maintain a high index of suspicion for cerebrovascular injury in these patients, as rapid diagnosis and emergent management can prevent devastating neurological outcomes. Data on management of cerebrovascular injury in pregnant and postpartum patients are limited, but management of maternal stroke in the emergency department aligns closely with protocols established for nonpregnant patients. This issue discusses the risk factors associated with maternal stroke, and reviews the available evidence for emergency department management of maternal stroke, including thrombolytic and interventional therapies.

Case Presentations

EMS arrives at the ED with a 29-year-old woman who is at 30 weeks and 2 days' gestation. She is experiencing word-finding difficulty and right-sided weakness…

• She is G2P1. She is accompanied by her mother, who reports that 2 hours ago, the patient suddenly became unable to speak in the middle of a conversation. There was also an observed right facial droop and difficulty moving her right arm.
• The patient's mother says that her daughter is otherwise healthy, does not take any medications, and has had an unremarkable pregnancy thus far.
• You call a code stroke and immediately check the patient's blood pressure, which is 128/85 mm Hg. On exam, she has notable aphasia, right facial droop, and right arm flaccidity, with a total NIHSS score of 25.
• What emergent labs should you order for this patient? What imaging is indicated? Is this patient a candidate for any interventions?

A 32-year-old woman presents to the ED with 3 days of worsening headache and visual changes, 1 week after delivering a baby…

• She is G1P1 and had a healthy pregnancy and delivery.
• She says she frequently experiences migraines, but this headache “feels different.” In contrast to her typical migraine, this new headache involves the whole head and is worse when she is lying down.
• What are the “can’t-miss” diagnoses in a postpartum patient who presents to the ED with a new headache? Should this patient undergo any imaging? If so, how urgently?

A 30-year-old woman at 33 weeks’ gestation is brought in by EMS after a witnessed collapse…

• Bystanders at a community picnic say the woman initially appeared well but suddenly complained of a severe headache and fell to the ground. When EMS arrived at the scene, the patient was unresponsive. Her blood pressure was 160/95 mm Hg and GCS score was 8. She was intubated in the field.
• A code stroke is activated upon her arrival in the ED, where her repeat blood pressure is 155/87 mm Hg. She is on minimal sedation but does not follow commands or meaningfully track.
• She is G3P2 and has no other past medical history. On exam, both pupils are dilated and sluggishly reactive, and she has no movement in the left arm or left leg, while she withdraws her right upper and lower extremities to noxious stimuli. You estimate her NIHSS score at 24. Her blood glucose level is 110 mg/dL.
• What is the best approach for the management of this patient’s blood pressure?

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.