What is the antiplatelet therapy for acute stroke in pregnancy?

From the Guidelines

Antiplatelet therapy for acute stroke in pregnancy should be approached cautiously with low-dose aspirin (81-100 mg daily) as the preferred agent, initiated as soon as possible after stroke diagnosis and continued throughout pregnancy, as recommended by the American Heart Association/American Stroke Association guidelines 1.

Key Considerations

• The presence of high-risk thromboembolic conditions, such as hypercoagulable state or mechanical heart valves, may require alternative anticoagulation options, including adjusted-dose unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) throughout pregnancy 1.
• In the absence of high-risk thromboembolic conditions, pregnant women with stroke or transient ischemic attack (TIA) may be considered for treatment with UFH or LMWH throughout the first trimester, followed by low-dose aspirin for the remainder of the pregnancy 1.
• Clopidogrel is typically avoided during pregnancy due to limited safety data, but may be considered in cases where aspirin is contraindicated or the stroke risk is particularly high.
• Dual antiplatelet therapy carries increased bleeding risks and should be used only in select high-risk cases.

Monitoring and Management

• Any antiplatelet therapy decision should involve a multidisciplinary approach, including neurology, obstetrics, and maternal-fetal medicine specialists, to balance stroke prevention with maternal and fetal safety.
• Treatment should be accompanied by close monitoring of both maternal and fetal well-being, with particular attention to bleeding risks.
• Aspirin should be discontinued 5-7 days before anticipated delivery to minimize peripartum bleeding complications and resumed postpartum as appropriate.

Evidence-Based Recommendations

• The American Heart Association/American Stroke Association guidelines provide recommendations for stroke prevention in pregnant women, including the use of low-dose aspirin and alternative anticoagulation options 1.
• A recent detailed discussion of options for stroke prevention during pregnancy is available from a writing group of the American College of Chest Physicians, which highlights the importance of individualized treatment decisions based on the presence of high-risk conditions and the potential risks and benefits of anticoagulation therapy 1.

From the FDA Drug Label

If pregnant or breast-feeding ask a health professional before use. it is especially important to use aspirin during the last 3 months of pregnancy unless definitely directed to do so by a doctor because it my cause problems in the unborn child or complications during delivery. The use of aspirin as an antiplatelet therapy for acute stroke in pregnancy is not directly supported by the drug label.

• The label advises against using aspirin during the last 3 months of pregnancy unless directed by a doctor.
• There is no explicit recommendation for the use of aspirin in acute stroke during pregnancy. 2

From the Research

Antiplatelt Therapy for Acute Stroke in Pregnancy

• The use of antiplatelet agents for acute stroke in pregnancy is indicated for secondary prevention 3, 4.
• Aspirin up to 150 mg daily is considered well tolerated during pregnancy and lactation period 3.
• Therapeutic anticoagulation during the acute management of ischemic stroke is not indicated due to an increased risk of hemorrhagic transformation 4.
• Antiplatelet agents are used for secondary prevention, but the management of cerebral venous sinus thrombosis, carotid and vertebral dissections, and reversible cerebral vasoconstrictive disease should follow the same guidelines as for nonpregnant individuals 4.

Management of Acute Ischemic Stroke

• Reperfusion therapies, including intravenous tissue plasminogen activator (tPA) and endovascular thrombectomy, should not be withheld from pregnant women with moderate-to-severe stroke when benefits outweigh the risk 3, 5, 4, 6.
• Patients presenting within 4.5 hours of symptom onset and with an initial normal head CT scan are candidates for alteplase (tPA) 4.
• Blood pressure control is paramount when administering tPA, and during pregnancy, it is recommended to maintain a blood pressure between 140-160/90-110 mm Hg during tPA treatment 4.
• Pregnancy should not be a contraindication for mechanical thrombectomy in carefully selected patients 4.

Diagnostic Testing and Initial Emergency Management

• MRI is the most accurate and well-tolerated diagnostic option, but low-dose CT-head is a valid alternative 3.
• A head computed tomography (CT) without contrast media should be performed without delay to rule out a hemorrhagic component 4.
• Initial emergency management should include aggressive treatment of fever, avoidance of hypotonic maintenance fluids, and maintenance of normal serum sodium levels 4.
• Serum glucose levels should be kept between 140 and 180 mg/dL 4.