Cerebrovascular disease in pregnancy

Cerebrovascular disease in pregnancy poses challenges to clinicians because of the difficulty in diagnosing the underlying etiology as well as the potential fetal toxicity of diagnostic testing and treatment. The underlying etiology for stroke in the pregnant patient must be aggressively sought and is critical to appropriate therapy: 1) If the arterial ischemic event in a pregnant patient remains cryptogenic, then either low-dose aspirin or another antithrombotic agent should be used. 2) Unfractionated heparin, or preferably, low molecular weight heparin, should be used to treat patients with a clearly identified etiology for which there is a specific clinical indication with at risk or symptomatic doses. Warfarin may be used in occasional cases when heparin is contraindicated (heparin-induced thrombocytopenia) and should be limited to the period after organogenesis in the second and third trimesters. 3) Using a heparin-warfarin-heparin alternating schedule to offset adverse events is impractical, because with each change in medications sustained anticoagulation cannot be easily obtained.