Abstract
Pregnancy-associated stroke (PAS) remains a leading cause of maternal mortality and the most frequent cause of severe long-term physical and cognitive disability after pregnancy. The initial evaluation of acute ischemic stroke (AIS) is similar to that of other emergencies. Immediate stabilization of the airway, breathing, and circulation is established. The next step is assessing the neurologic deficit. The most relevant detail of the patient's history is the time of symptom onset. A neurologic examination using a standardized scoring system such as the National Institutes of Health Stroke Scale is strongly advised. Imaging is quintessential in evaluating all cases for which a stroke is suspected. Non-contrast computed tomography has a sensitivity close to 100% for detecting intracranial hemorrhage, and it is usually the first test to be obtained. Magnetic resonance with diffusion-weighted imaging is the most sensitive and specific technique for detecting ischemic stroke. However, it is usually less immediately available. Differential diagnosis includes but is not limited to migraine headaches with aura, seizures, functional disorders, hypoglycemia, and multiple sclerosis. Treatment of stroke is a complex decision that must be made expeditiously. Recombinant tissue plasminogen activator should be used when the risks outweigh the benefits. In the case of large vessel occlusion, endovascular mechanical thrombectomy is preferred. It is unclear whether corticosteroids have a detrimental effect on patients with AIS. Therefore, administering corticosteroids between 24 and 34 weeks of gestation for fetal indications should be performed only if the delivery is imminent within the following week. One should have no reservations about using magnesium sulfate for obstetric indications in patients with PAS. If the fetal gestational age is beyond the threshold of fetal viability, one should decide on the timing and frequency of antenatal fetal monitoring based on the maternal condition and fetal status and whether interventions for fetal indications will be carried out. Generally, intrapartum fetal monitoring is continuous, although there is space for individualization. The delivery timing is generally based on obstetric indications unless delivery is thought to positively affect maternal well-being. In most cases, vaginal delivery with an assisted second stage is appropriate. When cesarean delivery is necessary, alternatives to general anesthesia should be considered to avoid sedation and hemodynamic changes inherent to intubation/ extubation. Recognition and interventions in AIS are time-sensitive. As women who suffer a stroke are more likely to be misdiagnosed and pregnancy imposes unique challenges, the obstetrician's role in early recognition, co-management, and care coordination is paramount.