Systemic thrombolysis for stroke in pregnancy

Pregnancy is an exclusion criterion for all clinical trials that validate alteplase in acute stroke, so our knowledge about its use in this condition is relative only to case reports and case series. Herein, we report the successful use of intravenous recombinant tissue-type plasminogen activator (rt-PA) in pregnant women with acute stroke. The patient was a 28-year-old who was 16 weeks pregnant. She presented to our hospital 1 hour after a sudden onset of mothor aphasia, hemiparesis, and hypoesthesia on the right side due to incipient ischemia in the left cerebral hemisphere resulting from ipsilateral middle cerebral artery subocclusion demonstrated by magnetic resonance imaging. After intravenous recombinant tissue-type plasminogen activator administration, she improved within a few hours, persisting only a slight motory aphasia. A transesophageal echocardiography showed a large patent foramen ovale with right to left shunt. Although the probable origin of stroke secondary to paradoxical embolism, we decided to treat the patient with acetylsalicylic acid. After the discharge, pregnancy was regular, and the patient delivered a healthy term infant without complications, and the puerperium was normal. To date, only 7 patients treated with intravenous alteplase for stroke has been reported. The fetal outcome was good in 5 cases, whereas in 2 patients were recorded minor hemorrhagic episodes and 1 patient died of dissection during angioplasty. With 1 exception, mothers recovered well from their strokes. Based on our case and reports obtained from literature, it seems that pregnant women generally can be safely treated with rt-PA systemic thrombolysis having a good outcome.