Cerebral venous thrombosis and pregnancy

Updated on 01/12/2023, published on 01/12/2023

  • cerebral venous thrombosis (CVT) is a rare but life-threatening disease in pregnant women
  • pregnancy increases the risk of CVT due to hormonal changes and blood flow alterations, especially during the third trimester and the postpartum period (5-20% of the cases)
  • other important risk factors include genetic thrombophilia, systemic diseases, infections, and cancer
  • symptoms are the same as in nonpregnant individuals and may include headache, vision changes, seizures, weakness, nausea, and vomiting
  • diagnosis is preferably made by using magnetic resonance imaging (MRI)/MR-venography due to the non-ionizing and non-invasive character
    • Time Of Flight (TOF) MR venography should be used
    • the use of contrast should be limited and only used when the benefits outweigh the possible risks for the fetus
  • CT+CT venography if MRI/MRV is contraindicated or unavailable (careful fetal shielding with a lead apron is required!)
    • CT venography is assumed to be as accurate as MR venography
    • CT has reduced sensitivity for detecting cortical vein thrombosis and early parenchymal lesions compared to MRI

→ Neuroimaging in pregnancy

  • if CVT is suspected during pregnancy or puerperium, one can consider cerebral imaging instead of measuring D-dimers
  • D-dimers are unspecific and tend to be increased due to the increased fibrinolysis following fibrin formation throughout pregnancy
  • standard treatment of CVT in pregnant and puerperal patients is anticoagulation
    • subcutaneous LMWH throughout the whole pregnancy is preferred due to its safety profile
      • LMWH does not cross the placenta and has a good safety profile; studies reported more favorable outcomes without significant risks of hemorrhagic complications in both the mother and fetus
    • UFH has the advantage of a short half-life with dose adjustments based on APTT and can be antagonized using protamine sulfate
      • although UFH has been assumed to be safe in pregnancy, associations with increased risk of fetal bleeding and teratogenicity have also been described
    • vitamin K antagonists are contraindicated during pregnancy
    • DOACs, such as factor Xa inhibitors (apixaban, edoxaban, rivaroxaban) or thrombin inhibitors (dabigatran), are also contraindicated because they are likely to cross the placenta and teratogenic risks are not well known
  • in severe cases or if anticoagulation therapy fails, endovascular treatment or surgery (life-saving decompressive craniectomy) may be effective (Zhou, 2022)
    • only case reports of endovascular treatment and decompressive craniectomy in pregnant women with CVT have been published
  • other treatments are symptomatic, addressing issues like seizures
  • the optimal dose of LMWH for thromboprophylaxis in pregnant women at moderate to high risk of venous thromboembolism recurrence is unknown
  • prophylactic or intermediate doses of LMWH are currently two options, of which the prophylactic dose is the most often prescribed in the clinical setting
    • intermediate doses: enoxaparin 0.5 mg-1 mg/kg administered subcutaneously once or twice daily
    • prophylactic dose: enoxaparin 0,4 ml (40 mg) SC once daily
    • dose reduction is required in renal insufficiency
  • therapeutic doses of LMWH are not widely accepted because of the possible bleeding risk during delivery
  • as for nonpregnant women, a treatment period of 3–12 months can be advised (based on individual risk factors)
  • therapeutic LMWH is typically continued for at least 6 weeks postpartum based on the known increased risk of CVT following delivery
  • consider the mother’s wish regarding breastfeeding in the case of a lifelong indication for anticoagulation after the puerperium period
  • LMWH is the gold standard during breastfeeding because it does not transfer easily into breastmilk
  • UFH and warfarin are also acceptable during lactation
  • DOACs should be avoided as no clinical data is available about their safety during lactation
  • women with a history of CVT face an increased risk of venous thromboembolism in future pregnancies
  • therefore, thromboprophylaxis with LMWH is recommended throughout pregnancy and the postpartum period
    • prophylactic LMWH seems appropriate (unless contraindicated or full anticoagulation is indicated) (ESO guidelines 2017
    • in the US, LMWH is administered from the 3rd trimester to the 8th week postpartum
    • data are weak and mostly from observational studies
  • thromboprophylaxis with LMWH is considered safe and effective in preventing recurrent venous thromboembolism, though it may be associated with an increased risk of late obstetrical complications
  • prevention strategies include staying hydrated, maintaining physical activity as advised, and regular medical check-ups
  • prophylactic dose of LMWH in women with a history of clotting disorders may be considered (consult a hematologist)
  • women with a history of CVT are advised against using estrogen-containing contraception due to the increased risk of recurrent CVT or other venous thromboembolic events
  • instead, an intrauterine contraceptive device (IUD) is recommended
  • progestogen-only contraceptives may be an alternative, but data on their safety is limited

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Cerebral venous thrombosis and pregnancy
link: https://www.stroke-manual.com/cerebral-venous-thrombosis-and-pregnancy/