In this episode I’ll discuss giving alteplase for acute ischemic stroke during pregnancy.
Although acute ischemic stroke is a rare occurrence during pregnancy, it is responsible for about 7% of maternal deaths in the US.
Two case reports and a review article of giving alteplase during pregnancy were recently published in the journal Pharmacotherapy.
The first case was a 26-year-old woman who was 12 weeks pregnant. She presented with acute ischemic stroke about 60 minutes after the onset of symptoms. She was experiencing expressive aphasia and right hemiparesis with an NIHSS of 29. A CT scan did not show evidence of intracranial hemorrhage (ICH). Before alteplase was given the symptoms completely resolved. 30 minutes later a recurrence of symptoms occurred but they were less severe with an NIHSS of 4. At this time an MRI was performed that showed an ischemic infarct and no ICH. The standard dose of alteplase was given for a 64 kg patient. She was discharged and later gave birth at 34 weeks without complication. The baby did get admitted to NICU for prematurity complications but did not have any birth defects.
The second case was a 24-year-old woman who was 30 weeks pregnant. She presented 30 minutes after acute-onset right hemiparesis, right upper extremity sensory loss, and dysarthria with an initial NIHSS score of 12. She had a history of DVT, obesity, and smoking. A CT had identified no ICH and alteplase was initiated. She delivered a healthy baby at 39 weeks with no complications.
The authors of the review article were able to locate a total of 27 case reports of alteplase being given to a pregnant patient. A review of these cases did not present a concern for negative outcomes on the fetus or mother beyond what is normally expected of alteplase. This data matches reviews of databases as well.
Of the available case reports, only 5 have a negative outcome reported, and from this list, only the last 2 cases are likely related to alteplase:
In negative case #1, the mother elected to terminate the pregnancy. She did have an intrauterine hematoma but this was managed conservatively.
In negative case #2, the mother elected to terminate the pregnancy and have bilateral tubal ligation.
In negative case #3, both the mother and fetus died after the mother developed an arterial dissection as a complication of cerebral angioplasty. This negative outcome was felt to be the result of the procedure and not the alteplase.
In negative case #4, there was a possible gestational sac hemorrhage. The pregnancy ended in miscarriage although the patient did have a history of 11 prior miscarriages.
In negative case #5, the fetus was deceased although reduced fetal movement had been reported by the mother 24 hours prior to the administration of alteplase.
The remainder of the 27 case reports resulted in a healthy birth.
In 3 of the cases, the mother experienced a hemorrhagic transformation of the stroke after alteplase was administered. All 3 cases had complete or near complete neurological recovery.
As these cases and review demonstrate, pregnancy alone is not a contraindication for alteplase if the mother is experiencing an acute ischemic stroke.
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