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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 2  |  Issue : 2  |  Page : 91-93

Cerebrovascular accident complicating severe preeclampsia: A rare case report


1 Department of Obstetrics and Gynaecology, College of Medical Sciences, Barau Dikko Teaching Hospital, Kaduna State University, Kaduna, Nigeria
2 Department of Obstetrics and Gynaecology, Jos University Teaching Hospital, Jos, Nigeria
3 Department of Medicine, College of Medical Sciences, Barau Dikko Teaching Hospital, Kaduna State University, Kaduna, Nigeria

Date of Web Publication30-Apr-2018

Correspondence Address:
Dr. Caleb Mohammed
Department of Obstetrics and Gynaecology, College of Medical Sciences, Barau Dikko Teaching Hospital, Kaduna State University, Kaduna
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/archms.archms_38_17

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  Abstract 

Stroke is a major contributor to morbidity and mortality during pregnancy and puerperium. The most important risk factor of stroke in pregnancy is preeclampsia and eclampsia. The occurrence of cerebrovascular event in preeclampsia is often associated with a higher likelihood of mortality if not managed appropriately and in a timely fashion. A 32-year-old multiparous patient at 34 weeks 5 days of gestation presented to our hospital with 9 h history of headache, inability to speak, and inability to move the right side of her body. On examination, she was aphasic, had elevated blood pressure, right-sided hemiplegia, and significant proteinuria. A diagnosis of severe preeclampsia with cerebrovascular accident was made. She was jointly managed with the cardiologist and physiotherapist. She was commenced on antihypertensive and magnesium sulphate and was delivered of a live baby boy weighing 2.0kg through an emergency lower segment cesarean section. Pregnancy-related stroke is rare. There should be a high index of suspicion among caregivers, and multidisciplinary management is the key.

Keywords: Cerebrovascular accident, multidisciplinary management, preeclampsia


How to cite this article:
Mohammed C, Adze JA, Bature SB, Amina MD, Matthew TC, Amina A, Musa J, Yakubu PD. Cerebrovascular accident complicating severe preeclampsia: A rare case report. Arch Med Surg 2017;2:91-3

How to cite this URL:
Mohammed C, Adze JA, Bature SB, Amina MD, Matthew TC, Amina A, Musa J, Yakubu PD. Cerebrovascular accident complicating severe preeclampsia: A rare case report. Arch Med Surg [serial online] 2017 [cited 2019 Dec 15];2:91-3. Available from: http://www.archms.org/text.asp?2017/2/2/91/231630


  Introduction Top


Stroke is a significant cause of morbidity and mortality worldwide. Stroke is a rare event in young people. However, stroke related to pregnancy accounts for about 30% of stroke in young people.[1] The most important risk factor for pregnant women is preeclampsia and eclampsia.[2],[3] Preeclampsia is a pregnancy-specific disorder characterized by hypertension (blood pressure [BP] ≥140/90 mmHg) measured twice 4 h apart after 20 weeks of pregnancy without prior hypertension together with proteinuria >300 mg/24 h.[4]

When clinical state suggests stroke in pregnant women with severe preeclampsia/eclampsia, it is necessary to immediately implement hypotensive treatment, intravenous magnesium sulphate, and pregnancy resolved by cesarean section.[5] Careful observation and rapid management can save mother and baby with severe preeclampsia complicated with cerebrovascular accident.


  Case Report Top


A 32-year-old woman, G4P3 + 0 (3 alive), last menstrual period 2/5/16, estimated due date – 9/2/17, estimated gestational age (EGA) – 34 weeks 5 days, presented at the accident and emergency unit of Barau Dikko Teaching Hospital Kaduna state, Nigeria, on January 3, 2017, with 8 h history of headache, sudden inability to speak, and inability to move her right upper and lower limbs. She also had a headache that was global in nature and associated with blurring of vision and epigastric pain. Her inability to use the right upper and lower extremities occurred few minutes following headache. There was no associated convulsion.

She booked the index pregnancy and was diagnosed to have pregnancy-induced hypertension at 33 weeks of gestation. The hypertension was controlled with appropriate oral antihypertensive medications. She had past history of pregnancy-induced hypertension in her 3rd pregnancy but did not have a family history of hypertension or stroke.

On examination, she was a young woman, afebrile, not pale, with motor aphasia. Her blood pressure (BP) was 140/90 mmHg, muscle power in the right upper limb (RUL) was 0/5, and right lower limb (RLL) was 2/5 but was normal on the left limbs. She had no signs of meningeal irritation. The uterus was 35 cm, with a singleton fetus in longitudinal lie, cephalic presentation, and good fetal heart tone. Urinalysis was 3+ of protein measured by qualitative dipstick method. A working diagnosis of severe preeclampsia with cerebrovascular accident was made.

Results of investigations were as follows: urinalysis: protein 3+; random blood sugar: 5.3 mmol/l, urea; electrolytes and creatinine: essentially normal, uric acid 625 Umol/l (142–339); liver function test: aspartate transaminase 16 (0–12), alanine transaminase 17 (0–12), alkaline phosphatase 57 (9–35), total bilirubin <17; Hb/PCV: 12.5 g/dl (37.5%); obstetric ultrasound scan: EGA 33 weeks, estimated fetal weight 2.3 kg. Consult was sent to cardiologist, neonatologist, and physiotherapist.

She was commenced on MgSO4 according to Pritchard regimen. She had an emergency lower segment cesarean section done after 24 h of admission when she completed MgSO4, under general anesthesia and was delivered of a live baby girl that weighed 2.0 kg with APGAR of 8 and 10 in the 1st and 5th min, respectively. Estimated blood loss was 550 ml. The baby was taken to Neonatal Intensive Care Unit.

On the 2nd day of admission, cardiologist review. She was fully conscious, but still motor aphasic, with deviation of angle of the mouth to the right, but forehead wrinkles were preserved and was able to close the eyes firmly (features of left facial nerve palsy upper motor neuron type). She had inability to move right side of the body, motor power, RUL 0/5, RLL 2/5(features of left cranial nerve palsy, upper motor neuron type). Her pulse rate was 80 bpm, and BP was 170/120 mmHg. Assessment of left hemispheric stroke likely ischemic complicating preeclampsia was made. Brain computerized tomographic (CT) scan done after the cesarean section showed a 3.2 cm hyperdense region in the left parietal lobe with surrounding hypodensity due to clot retraction. The remaining brain mantle and ventricles were within normal limits. The cerebellum and cerebellopontine angles were preserved. The CT diagnosis was left parietal hemorrhagic stroke [Figure 1]a and [Figure 1]b. She was placed on α-Tocopherol (Vitamin E isomer) 50 mg daily, tabs ascorbic acid (Vitamin C) 100 mg trice daily, Intra venous fluid (IVF) dextrose saline 1 L 8 hourly, and was maintained on alpha methyldopa 250 mg twice daily (avoid additional antihypertensives). She was observed closely with strict input/output chart, bowel, and bladder care. Consult of a neurologist and physiotherapist was sought.
Figure 1: (a and b) Brain computerized tomographic showing left parietal hemorrhage

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The physiotherapist recommended incentric spirometry (modified), SQC (static Quadriceps) exercise to RLL, passive movement/proprioceptive neuromuscular facilitation (PM/PNF) to RUL and RLL and auto-assisted exercise. The patient continued physiotherapy and antihypertensive.

Three weeks after admission, she maintained satisfactory improvement in her clinical condition and started communicating. Her BP was 120/80 mmHg, power RLL was 4/5, UL 0/5. She was discharged home to continue physiotherapy as an outpatient and to be followed up in the cardiology clinic. Six weeks into follow-up, the patient regained both limbs function and had no neurological deficit.


  Discussion Top


The incidence of both ischemic and hemorrhagic stroke is increased in preeclampsia and eclampsia.[6] The overall incidence of ischemic stroke during pregnancy is low (3.5–5/100,000 pregnancies) in the developed countries with the majority of these events occurring late in pregnancy and postpartum period.[1] However, when considering stroke in the young people, it has been estimated that related to pregnancy accounts for 12%–35% of stroke events in this otherwise low-risk populate.[1] Stroke with preeclampsia is likely of the hemorrhagic type.[7] This was the case in the patient presented above. One of the most common risk factors for stroke in pregnancy is preeclampsia/eclampsia.[8] A similar case report on complete recovery of a primigravida with hemorrhagic stroke due to severe preeclampsia was reported in Abuja.[1] In the most recent nation-wide impatient sample, epidemiological study of stroke in pregnancy, preeclampsia/eclampsia was associated with a 4-fold increased risk of stroke [8] and accounts for 5%–12% of overall maternal mortality.[1]

The patient may present clinically with headache, altered consciousness, and seizure, focal neurological or visual disturbance.[8],[9] Our patient presented with headache, visual disturbance, and focal neurology (aphasia and inability to move right upper and lower limbs).

Neuroimaging is indicated in all pregnant patients whose clinical condition is suggestive of a cerebrovascular event.[6] Magnetic resonance imaging (MRI) is well known for its far more soft-tissue contrast and multiplanar resolution compared with CT.[6],[10] This patient had a CT done dueto nonavailability of MRI.

Management is optimized by the early involvement of a senior multidisciplinary team.[5],[6],[11] This patient was attended by the obstetrician, cardiologist, anesthesiologist, and physiotherapist.

Control of hypertension in patient with hemorrhagic stroke is necessary to minimize further bleeding, although this benefit must be balanced against the risk of cerebral ischemia.[6] Where required, intravenous antihypertensive agents should be used to control severe hypertension with suggested BP target of ≤160/110 mmHg. Our patient had MgSO4 to prevent convulsion [12] and oral antihypertensive (Aldomet). Labetolol has been suggested as the first-line agent for hypertension accompanying stroke in preeclampsia.[13] This was not used in this patient because of nonavailability at the time this patient presented in our facility. She was placed on IVF dextrose saline. Though normal saline is the most ideal fluid, this patient was given dextrose saline to prevent the risk of hypoglycemia in a postoperative period placed on nil per oral. Moreover, dextrose saline is indicated in stroke management guidelines as the alternative to normal saline. This is because dextrose saline being an isotonic fluid is less likely to worsen cerebral edema.[14] Vitamins C and E which are antioxidants were given to reduce the formation of free radicals such as superoxide which may cause more injury to the brain and worsen the outcome.[15] The timing of delivery will be influenced by fetal condition, gestational age, and severity of associated preeclampsia.[6] Choice of mode of delivery requires detailed anesthetic, neurological, and obstetric input to minimize maternal risk.[6] Our patient had emergency cesarean section after stabilization.


  Conclusion Top


Pregnancy-related stroke is a rare phenomenon; it is an important cause of morbidity and mortality among pregnant women. There should be a high index of suspicion among obstetricians for early diagnosis. Multidisciplinary management should be the bedrock of care. Adequate follow-up and rehabilitation should be an important component of the care.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Mbamara SU, Mbah IC, Ogbuagu L. Complete recovery of a booked primigravida with hemorrhagic stroke due to severe preeclampsia. J Basic Clin Reprod Sci 2016;5:46-51.  Back to cited text no. 1
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Ohno Y, Kawai M, Morikawa S, Sakakibara K, Tanaka K, Ishikawa K, et al. Management of eclampsia and stroke during pregnancy. Neurol Med Chir (Tokyo) 2013;53:513-9.  Back to cited text no. 11
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Naeimi A, Rieu M, Le Guen F, Marpeau L. Preeclampsia and benefit form magnesium sulfate. About 105 cases. Gynecol Obstet Fertil 2014;42:322-4.  Back to cited text no. 12
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Prasad K, Kaul S, Padma MV, Gorthi SP, Khurana D, Bakshi A, et al. Stroke management. Ann Indian Acad Neurol 2011;14:S82-96.  Back to cited text no. 14
    
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Gariballa SE, Hutchin TP, Sinclair AJ. Antioxidant capacity after acute ischaemic stroke. QJM 2002;95:685-90.  Back to cited text no. 15
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