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Reperfusion Therapy for Acute Stroke in Pregnant and Post-Partum Women: A Canadian Survey

Published online by Cambridge University Press:  22 September 2020

Christopher E. Uy
Affiliation:
Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
Stéphanie Gosselin-Lefebvre
Affiliation:
Service de Neurologie, Département de Médecine, Université Laval, Quebec City, QC, Canada
Adam M. Book
Affiliation:
Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada Vancouver Stroke Program and Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
Thalia S. Field*
Affiliation:
Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada Vancouver Stroke Program and Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
*
Correspondence to: Thalia S. Field, Associate Professor, University of British Columbia, S169-211 Wesbrook Mall, Vancouver, BC V6T 2B5, Canada. Email: thalia.field@ubc.ca

Abstract:

Background/objective:

A Canadian Stroke Best Practices consensus statement on Acute Stroke Management during pregnancy was published in 2018. The state of individual practice, however, is unknown.

Methods:

A survey on treatment of acute stroke in pregnant and post-partum women was distributed via the Canadian Stroke Consortium email list. Descriptive statistics (frequencies and proportions) were calculated for demographic and response variables and free-text responses were coded for thematic content.

Results:

Thirty-five participants completed the survey; 12 had experience with intravenous tissue plasminogen activator (IV-tPA), endovascular therapy (EVT), or both in pregnant patients. None had treatment-related complications. The majority (92%) of those who had not yet encountered the issue in practice expressed some reservation about giving IV-tPA to an otherwise eligible pregnant woman. In a theoretical scenario where an otherwise eligible pregnant woman was a candidate for both IV-tPA and EVT, 58% of respondents would have opted for EVT alone. Amongst this cohort comprised mainly of stroke sub-specialists, more than a third had treated pregnant patients with reperfusion therapy.

Conclusions:

The reported safety experience with both IV-tPA and EVT was reassuring. Overall, there was a hesitancy towards use of IV-tPA in pregnancy that is discordant with the recent consensus statement. Possible barriers to uptake identified through thematic analysis were concerns regarding risks of bleeding in the pregnant patient, presence of EVT as a perceived alternative, and the need for express consent from the patient and family.

Résumé :

RÉSUMÉ :

Offrir des traitements de reperfusion à des femmes enceintes ou qui viennent d’accoucher ayant été victimes d’un AVC aigu : un sondage canadien.

Contexte/objectif :

Une déclaration commune en lien avec les pratiques optimales de l’AVC au Canada et portant de façon plus particulière sur la prise en charge des AVC aigus durant la grossesse a été publiée en 2018. La pratique des médecins à ce sujet demeure toutefois encore méconnue.

Méthodes :

Un sondage portant sur le traitement des AVC aigus affectant des femmes enceintes ou des femmes qui viennent d’accoucher a ainsi été distribué par l’entremise de la liste de diffusion du Consortium neurovasculaire canadien (CNC). On a de la sorte pu obtenir des statistiques descriptives (fréquences et proportions) à propos des caractéristiques démographiques et des variables contenues dans les réponses ; de plus, les éléments de réponse élaborés plus librement ont été codés en vue d’extraire un contenu thématique.

Résultats :

Au total, 35 participants ont complété ce sondage. De ce nombre, 12 avaient de l’expérience avec l’activateur tissulaire du plasminogène (t-PA), la thérapie endovasculaire (TEV)) ou les deux dans le cas de patientes enceintes. Aucun d’entre eux n’a fait état de complications liées à ces traitements. La majorité de ceux n’ayant pas encore été confrontés à une telle situation clinique (92 %) dans leur pratique ont exprimé des réserves sur le fait de prodiguer un t-PA par intraveineuse à une femme enceinte par ailleurs admissible. Dans un scénario théorique en vertu duquel une femme enceinte admissible serait candidate aux deux traitements (t-PA et TEV), 58 % des répondants auraient opté pour la seule TEV. Parmi ce groupe de répondants composé principalement de sous-spécialistes des AVC, plus d’un tiers d’entre eux avaient traité des femmes enceintes au moyen de la thérapie de reperfusion.

Conclusions :

En matière de sécurité, l’expérience signalée par nos répondants, tant pour la T-PA que pour la TEV, s’est révélée rassurante. De façon générale, on a également noté une hésitation en ce qui regarde l’utilisation du t-PA par intraveineuse en cas de grossesse, ce qui constitue une contradiction par rapport à la récente déclaration commune évoquée ci-dessus. Notre analyse thématique nous a permis d’identifier de possibles obstacles à l’adoption de ce traitement : des préoccupations quant à des risques d’hémorragie chez des patientes enceintes ; la perception à l’effet que la TEV constitue une alternative ; et la nécessité d’obtenir le consentement explicite du patient et de sa famille.

Type
Original Article
Copyright
Copyright © The Author(s), 2020. Published by Cambridge University Press on behalf of The Canadian Journal of Neurological Sciences Inc.

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