What is the workup for a 20-week pregnant woman presenting with stroke-like symptoms and blurred vision?

From the Guidelines

A 20-week pregnant woman presenting with stroke-like symptoms and blurred vision requires immediate comprehensive evaluation and management to prevent maternal and fetal morbidity and mortality. The initial workup should include urgent neuroimaging with MRI without contrast (preferred) or CT scan if MRI is unavailable, as these are safe during pregnancy 1. Laboratory workup should include complete blood count, comprehensive metabolic panel, coagulation studies, and assessment for pregnancy-specific conditions like preeclampsia (blood pressure measurement, urine protein, liver enzymes, and platelet count) 1.

Key Considerations

• Consultation with a multidisciplinary team including neurology, maternal-fetal medicine, and obstetrics is essential to balance maternal benefit against fetal risk.
• Blood pressure management is critical, aiming for targets below 160/110 mmHg using pregnancy-safe medications like labetalol or nifedipine, as recommended by the European Society of Hypertension 1.
• These symptoms could indicate preeclampsia with severe features, posterior reversible encephalopathy syndrome, or cerebral venous thrombosis - all more common during pregnancy due to hypercoagulability and hemodynamic changes.
• Continuous fetal monitoring should be implemented, and delivery may be considered if the pregnancy is contributing to maternal risk and the fetus is viable.

Management Priorities

• Immediate evaluation and management of blood pressure to prevent stroke and other complications, with a focus on using medications that are safe during pregnancy, such as labetalol and nifedipine 1.
• Urgent neuroimaging to diagnose or rule out stroke, and to guide further management decisions 1.
• Multidisciplinary consultation to ensure comprehensive care and to balance maternal and fetal risks.
• Close monitoring of both the mother and the fetus to promptly address any changes in condition or new complications that may arise.

From the Research

Workup for Stroke-Like Symptoms in a 20-Week Pregnant Woman

The workup for a 20-week pregnant woman presenting with stroke-like symptoms and blurred vision involves a comprehensive assessment to determine the underlying cause of the symptoms.

• The patient's symptoms should be evaluated promptly, as stroke is a time-sensitive medical diagnosis 2.
• A thorough medical history should be taken, including any pre-existing medical conditions, to identify potential risk factors for stroke 3, 4.
• A physical examination, including a neurological examination, should be performed to assess for any focal deficits or signs of stroke 4, 2.
• Imaging studies, such as magnetic resonance imaging (MRI), should be considered to evaluate for any evidence of stroke or other underlying conditions 4, 5.
• An ophthalmologic evaluation should also be considered, as retinal transient ischemic attacks (TIAs) and visual symptoms can be a presenting feature of stroke 5.
• The patient's symptoms should be differentiated from other conditions, such as migraine with aura, which can present with similar symptoms 4.

Diagnostic Considerations

• The diagnosis of stroke in pregnancy can be challenging, and a multidisciplinary approach to care is recommended 4, 2.
• The patient's care should be managed by a team of healthcare providers, including obstetricians, neurologists, and ophthalmologists, to ensure prompt and appropriate treatment 2, 5.
• The workup should include an assessment for both ischemic and hemorrhagic stroke, as the treatment and management of these conditions differ significantly 2.