CNS and Liver in Pregnancy

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Transcript of CNS and Liver in Pregnancy

  • 1. CME ON MEDICAL DISORDERS IN PREGNANCY NERVOUS SYSTEM AND LIVER Prof. Dr. S Sundars Unit Dr. Deepu Sebin, PG in Internal Medicine

2. CNS in Pregnancy Liver Challenges us with the diagnosis Challenges are both in diagnosis and treatment Brain and Liver There are changes with pregnancy , but not much !Liver in Pregnancy CVAs and Seizures Pregnancy specific liver diseases 3. CVA during pregnancy

  • Pregnancy and the postpartum period are associated withamarked increase in the relative risk and a small increase in the absolute risk ofischemic stroke and intracerebral hemorrhage,with the highest risk during thepuerperium.

4.

  • Most cerebral infarctions associated with pregnancy are due toarterial occlusion , not cerebral venous thrombosis 1
  • Ischemic and hemorrhagic strokes have been reported in roughly equal proportions.
          • 1.Jaigobin and Silver ( Stroke , 2000), McGriger etal 2003, NEFh study 1999

5. Stroke and Pregnancy: Subarachnoid Hemorrhage

  • Subarachnoid hemorrhage (SAH) is a leading cause of non-obstetric-related maternal death Which is often not identified.
  • Incidence of SAH from aneurismal rupture in pregnancy ranges from 3 to 11 per 100,000 pregnancies 2
  • 50% of all aneurismal ruptures in women below the age of 40 years are pregnancy related 3

1. Visscher HC, Visscher RD. Indirect obstetric deaths in the state of Michigan 19601968. Am J Obstet Gynecol 1971;109:118796. 2. Sharshar T, Lamy C, Mas JL. Incidence and causes of strokes associated with pregnancy and puerperium: a study in public hospitals of Ile de France. Stroke 1995;26:9306. 3. Barrett JM, Van Hooydonk JE, Boehm FH. Pregnancy-related rupture of arterial aneurysms.Obstet Gynecol Surv1982;37:55766. 6. Risk Factors

  • Age >35 years
  • Black Ethnicity
  • HTN: Pre-eclampsia and Eclampsia
  • Hypercoagulable state of pregnancy
  • Heart Disease
  • Smoking
  • Diabetes
  • Lupus
  • Sickle Cell Disease
  • Migraine Headache
  • Alcohol and Substance Abuse
  • Caesarean Delivery
  • Fluid and Electrolyte Disorders
  • Thrombophilia
  • Multiple Gestation
  • Greater Parity
  • Postpartum Infection
  • AntiPhospholipid Antibody Syndrome
  • Gestational Trophoblastic Disorder
  • Peripartum cerebral angiopathy

7. Risk Factors Risk Factors

  • Age >35 years
  • Black Ethnicity
  • HTN: Pre-eclampsia and Eclampsia
  • Hypercoagulable state of pregnancy
  • Heart Disease
  • Smoking
  • Diabetes
  • Lupus
  • Sickle Cell Disease
  • Migraine Headache
  • Alcohol and Substance Abuse
  • Caesarean Delivery
  • Fluid and Electrolyte Disorders
  • Thrombophilia
  • Multiple Gestation
  • Greater Parity
  • Postpartum Infection
  • AntiPhospholipid Antibody Syndrome
  • Gestational Trophoblastic Disorder
  • Peripatrum Cerebral Angiopathy

8. Stroke and Pregnancy: Pre-eclampsia and Eclampsia

  • The proportion of patients with pregnancy-related stroke who havepre-eclampsia or eclampsia is 25-45% 1
  • Proposed mechanisms for increased risk of stroke in pre-eclampsia and eclampsia: 2
    • Endovascular dysfunction
    • Abnormal cerebral autoregulation resulting in higher cerebral perfusion pressures, which may result in barotrauma and vessel damage
    • Hemoconcentration due to third spacing of intravascular fluids
    • Activation of the coagulation cascade with micro-thrombi formation
  • Cerebral hemorrhageis the most common cause of death in women with eclampsia 3
  • Strokeis the most common cause ofdeath in women with HELLP syndrome 4
  • Women with a history ofpre-eclampsia are 60% more likely to have a non-pregnancy-related ischemic stroke 5

1. Sharshar T, Lamy C, Mas JL. Incidence and causes of strokes associated with pregnancy and puerperium: a study in public hospitals of Ile de France.Stroke1995;26:9306. 2. Treadwell SD, Thanvi B, Robinson TG. Stroke in pregnancy and the puerperium.Postgrad Med J of BMJ2008;84:238-45. 3. Okanloma KA, Moodley J. Neurological complications associated with the preeclampsia/eclampsia syndrome.Int J Gynaecol Obstet2000;71:2235. 4. Isler CM, Rinehart BK, Terrone DA, et al. Maternal mortality associated with HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome.Am J Obstet Gynecol1999;181:9248. 5. Brown DW, Dueker N, Jamieson DJ, et al. Preeclampsia and the risk of ischemic stroke among young women.Stroke2006;37:10559 . 9. 1. Bushnell CD, Jamison M, James AH. Migraines during pregnancy linked to stroke and vascular diseases: US population based case-control study.BMJ2009;338:b664. 10. Stroke and Pregnancy: Migraine

  • Migraine was thought to be associated with a with a17 -fold increased risk of pregnancy-related stroke 1
  • Large Inpatient Sample (2000-2003): 2
    • Strongest association between migraine and ischemic stroke (OR=30.7)
    • Intracranial hemorrhage strongly associated with migraine (OR=9.1)
    • Pre-eclampsia and venous thromboembolism/PE associated with migraine
    • CVT and SAH were not associated with migraine

1. James AH, Bushnell CD, Jamison MG, Myers ER. Incidence and risk factors for stroke in pregnancy and the puerperium.Obstet Gynecol2005;106:509-16. 2. Bushnell CD, Jamison M, James AH. Migraines during pregnancy linked to stroke and vascular diseases: US population based case-control study.BMJ2009;338:b664. 11. Stroke and Pregnancy: Migraine

  • Overlapping pathophysiological mechanisms exists.
  • Migrainershaveincreased peripheral and central blood pressure, a decreased diameter and compliance of superficial muscular arteries , anddecreased endothelial dilatation response to hyperemia compared to controls 1.
  • Active migraine during pregnancy can be viewed as a marker of vascular diseases, especially ischemic stroke 2.

1. Vanmolkot F, Van Bortel L, de Hoon J. Altered arterial function in migraine of recent onset.Neurology2007;68:1563-70. 2. Bushnell CD, Jamison M, James AH. Migraines during pregnancy linked to stroke and vascular diseases: US population based case-control study.BMJ2009;338:b664. 12.

    • Increased von Willebrand factor,Factor 8, fibrinogen
    • Reduced protein S concentrations
    • Increased plasminogen activator inhibitors 1 and 2
    • Platelet aggregation

Barotrauma during deliver due to raised ICP due to straining Gravid uterus compressing the vessels 13. Stroke and Pregnancy: Cerebral Vein Thrombosis (CVT)

  • Occlusion of the dural venous sinuses or cortical veins can result invenous infarction and hemorrhagewith associated focal neurological signs and symptoms
    • Impaired absorption of CSF
    • Intracranial HTN
    • Headache, vomiting, papilledema
    • Seizures, coma, death
  • Risk of CVT is increased in the puerperium due to pregnancy-related hypercoagulability
  • Incidence rate of 11.6 cases of peripartum CVT per 100,000 deliveries 1

1. Lanska DJ, Kryscio RJ. Risk factors for peripartum and postpartum stroke and intracranial venous thrombosis.Stroke2000;31:127482. 14. Stroke and Pregnancy: Cerebral Vein Thrombosis (CVT)

  • Treatment is complicated by uncertainty regarding the safety of antithrombotic agents during pregnancy
  • Low dose aspirin appears to be safe for the fetus after the first trimester
  • Warfarin may be safe for the fetus after the first 12 weeks, but is not usually recommended during pregnancy because of teratogenic risk
  • American Heart Association/American Stroke Association recommendations for high-risk thromboembolic complications in pregnancy:
    • Adjusted-dose unfractionated (UFH) heparin throughout pregnancy with PTT monitoring
    • Adjusted-dose low-molecular-weight heparin (LMWH) throughout pregnancy with factor Xa monitoring
    • UFH or LMWH until week 13 followed by warfarin until the middle of the third trimester, when UFH or LMWH is reinstituted until delivery 1

1. Sacco RL, Adams R, Albers G, et al. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack.Stroke2006;37:577617. 15. Stroke and Pregnancy: Postpartum Cerebral Angiopathy

  • Postpartum cerebral angiopathy (PCA) is a cerebral vasoconstriction syndrome
  • Also known as eclamptic vasospasm or Call-Fleming syndrome