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British Journal of Healthcare and Medical Research - Vol. 10, No. 6
Publication Date: December 25, 2023
DOI:10.14738/bjhmr.106.16114.
Jayyar, L., Othman, B., & Othman, M. (2023). Cerebral Venous Thrombosis During Pregnancy: Tertiary Centre Experience. British
Journal of Healthcare and Medical Research, Vol - 10(6). 319-324.
Services for Science and Education – United Kingdom
Cerebral Venous Thrombosis During Pregnancy: Tertiary Centre
Experience
Lamyaa Jayyar
King Salman Bin Abdulaziz Medical City (KSAMC),
Madinah, Saudi Arabia
Basil Othman
College of Medicine, Taibah University,
Madinah, Saudi Arabia
Mohammad Othman
Fakeeh College for Medical Sciences,
Jeddah, Saudi Arabia
ABSTRACT
Introduction: Cerebral venous thrombosis (CVT) is a rare variant of stroke in the
general population, but an important subtype among pregnancy- and puerperium- related cases. Studies describing its risk factors and clinical characteristics are
limited. The aim is to study the prevalence of CVT with pregnancy in King Salman
Bin Abdulaziz Medical City (KSAMC) for the past 23 years. In addition, detailing the
presentation, symptoms, diagnosis and management of these patients. Methods:
This a retrospective study to review files of pregnant women who was diagnosed as
having CVT between first of January 2000 and end of October 2023. Aiming to study
the prevalence of CVT with pregnancy in the past 23 years. In addition, detailing the
presentation, symptoms, diagnosis and management of these patients. Results:
There is only one patient with CVT during pregnancy out of 410355 deliveries in the
past 23 years. Patient was diagnosed using MRI- venography. She was started on
LMWH and patient delivered vaginally baby boy in good condition. Discussion:
prevalence of CVT during pregnancy is 0.0002% and the incidence is 1case /
10,000,000 pregnancy per year. Normal physiological changes during first
trimester may increase the risk of CVT. Conclusion: This finding of this study may
provoke researchers in the country to study CVT during pregnancy on the national
level to study such and important neurological issue during pregnancy.
Keywords: Cerebral venous thrombosis, Pregnancy, CT scan, Ultrasound, Hypertension,
Beta Blockers, Progesterone, Estrogen, IUGR.
INTRODUCTION
Cerebrovascular issues are unusual however could have life-threatening and potentially
disabling headaches all through pregnancy and the postpartum period. They pose vast dangers
for each the pregnant woman and baby. They can be divided into two fundamental categories:
thrombosis and ischemia, which consist of arterial and venous strokes and haemorrhage [1, 2].
there may be large variability inside the prevalence of stroke in pregnancy and puerperium,
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encouraged via healthcare systems, geographical regions, look at populations, and look at
designs. based totally on a systematic evaluation and meta-analyses, the pooled crude charge
of stroke related to pregnancy turned into 30 instances in 100,000 pregnancies, with kind of
identical rates among ischemic stroke, cerebral haemorrhage, and cerebral venous thrombosis
(CVT) [3]. CVT represents 2–57% of strokes associated with pregnancy [4-10]. The majority of
instances seem in the postpartum period [11].
being pregnant and postpartum period are related to complicated physiological changes and
adaptation mechanisms, which can result in altered homeostasis and a high chance of
headaches [1]. the primary causes for elevated CVT risk for the duration of the postpartum
period are the hypercoagulability related to pregnancy, cesarean delivery, infections, blood
loss, dehydration, fluctuations of intracranial stress during exertions and hypertensive
headaches of being pregnant [12, 13]. The prothrombotic stat for the duration of being
pregnant effects from a shift in the equilibrium among the fibrinolytic and haemostatic system
to save excessive haemorrhage all through exertions. there's an improved stage of procoagulant
elements, in addition to a decreased degree of anticoagulant factors which include protein S
and C and reduced fibrinolytic activity. these haematological adjustments return to baseline
most effective sex–eight weeks after transport [14-18]. A cesarean section contributes to the
higher rates of CVT in puerperium. Most likely because the surgery caused tissue destruction
results in increased thrombin activity, protein C activation and accelerated clearance from
plasma. The surgical procedure-triggered decrease of protein C stat. This is due to pregnancy- related protein C resistance, resulting in increased threat of thrombosis [1]. The pregnancy- and delivery-related anemia can lead to thrombocytosis, which is a risk aspect for venous
thrombosis [19].
Cerebral venous thrombosis is an unprecedented cause of stroke affecting all age groups,
however with pregnancy because of hormone-related risk elements it is higher. Because of this
and the nonspecific presentation of CVT with pregnancy, the diagnosis is tough, regularly
delayed, and desires a high clinical organisation. Characteristically, in case of early diagnosis
the outcomes are great and more beneficial to the patient [20].
This research aims to study the prevalence of CVT with pregnancy in King Salman Bin Abdulaziz
Medical City (KSAMC) for the past 23 years. Added to that, detailing the presentation,
symptoms, diagnosis and management of these patients.
METHODOLOGY
This is a retrospective study which was conducted in King Salman Bin Abdulaziz Medical City
(KSAMC), Obstetrics and Gynaecology department. This study review files of pregnant women
who was diagnosed as having CVT between first of January 2000 and end of November 2023.
This chart review was done in the medical record department. Included participants are
pregnant woman diagnosed as having CVT before or during pregnancy. All patients satisfy
previous condition will be included in the study and therefore no sample size calculation
needed.
The retrieved data included the following variables; demographic data of the participants (Age,
nationality, education, Gravidity and parity), number of visits, presence of CVT, when was
diagnosed, symptoms and signs, management of the participant, any side effects, mode of
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Jayyar, L., Othman, B., & Othman, M. (2023). Cerebral Venous Thrombosis During Pregnancy; Tertiary Centre Experience. British Journal of
Healthcare and Medical Research, Vol - 10(6). 319-324.
URL: http://dx.doi.org/10.14738/bjhmr.106.16114.
delivery, any maternal complications, neonatal APGAR score at 5 minutes, admission to NICU,
any neonatal complications and neonatal deaths.
Ethical practices ensured by protecting patients’ privacy and confidentiality by avoiding direct
patient identification. The data stored in a password-protected computer that only principal
researcher had access too. Data managed and analysed using Statistical Package for Social
Sciences version 28 (SPSS 28) [21], the P-value is considered statistically significant when it is
less than or equal to 0.05. For continuous variables, a student t-test will use to evaluate
differences in means between the groups. For categorical data, a chi-square test will use to
assess differences in proportions across the categories. Descriptive statistics will be used
whenever possible. These including quantitative variables summarization as either Mean and
Standard Deviation if normally distributed data or Median if data are skewed. While qualitative
variables will be calculated using frequency and percentage.
Ethical approval obtained from the ethics committee of King Salman Bin Abdulaziz Medical City
(KSAMC) by the number (23-059). All information provided for the purpose of the study will
be treated as strictly confidential and all participants will be kept anonymous.
RESULTS
There were 410355 deliveries between first of January 2000 until the end of November 2023.
Only one patient was identified as CVT with pregnancy during late 2023. This makes the
prevalence of CVT occurring during pregnancy in KSAMC is 1/410355, in other words 0.0002%.
Alternatively, the incidence in KSAMC is 1case / 10,000,000 pregnancy per year.
Patient was 25 years old with previous 2 vaginal deliveries and pregnant 8 weeks. Patient had
history of deep venous thrombosis (DVT) in her left leg in the first pregnancy. She was on low
molecular weight heparin (LMWH) during pregnancy then on warfarin 2 month postpartum.
She did not take any medication in the second pregnancy and this pregnancy which is 6 months
after last delivery. She presented in coma two hours post tonic clonic convulsions. She had
headache in occipital area and vomiting 4 days ago. CT scan showed superior sagittal sinus
thrombosis and MRI-venography showed right transverse venous sinus thrombosis (Figure 1).
Figure 1: patient MRI-venography showing right transverse venous sinus thrombosis
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Patient was diagnosed as CVT in first trimester of the pregnancy. She was followed by the
medical team and the Obstetrical team in the ICU then in ward. Eventually, patient was
discharged on full dose of LMWH twice daily until at 38 weeks patient admitted to the hospital
and LMWH stopped for 24 hours and induction started. Patient delivered vaginaly baby boy 3.1
kg’s with APGAR score of 8 at 1 minute and 9at 5 minutes. Patient kept on LMWH in the
postpartum period then was followed by the medical team in good condition.
DISCUSSION
Current research in KSAMC found that prevalence of CVT during pregnancy is 0.0002% and the
incidence is 1case / 10,000,000 pregnancy per year. On the other hand, the incidence in most
countries in the world are approximately 1 case / 100,000 pregnancies per year [22-25]. This
difference in the incidence is manly because all other studies are covering the incidence of the
country but this study covers only one tertiary centre in one large city in the country.
Accordingly, the result of this study cannot be generalized on the country but open the space
for researchers in Saudi Arabia to start looking at CVT in general and during pregnancy as
important research subject to study.
Many factors increase the risk of CVT during pregnancy. Vomiting during pregnancy and
increasing age are considered minor risk factors. This is because physiological increase in
cardiac output and plasma volume does not occur until late in the second trimester. So, during
the first trimester, there is an increase in systemic vascular resistance leading to lower blood
pressure coupled with increased venous capacity leading to venous stasis and raising the risk
of CVT [24]. On top of that, there is a physiological increase in the production of coagulation
factors VII, VIII, IX, and X. In addition, Increased platelet activation and decreased protein-S and
Antithrombin III concentrations. All these results in increase the risk of CVT [23, 24]. During
pregnancy, preeclampsia, eclampsia and HELLP syndrome are the most important disorders in
the second half of pregnancy that may increase risk for thromboembolic complications leading
to CVT [22, 24, 25].
CVT may present clinically as preeclampsia and progress gradually until it is seen as eclamptic
fits [13, 20]. Our patient complained mainly of headache then after four days had a seizure
followed by comma. Previous studies found that the most common clinical feature of CVT
during pregnancy to be headache followed by seizures then lastly followed by coma and visual
loss [23]. The preferred diagnostic method for CVT in pregnant women is preferably MRI- venography due to absence of radiation and non-invasive character of this method [3, 6].
The principal anticoagulant for CVT is warfarin. Unfortunately, warfarin crosses the placenta
causing teratogenicity in the first trimester and increase risk of intracranial haemorrhage in the
fetus in the third trimester [22, 24]. Accordingly, LMWH is the treatment of choice during
pregnancy. LMWH does not cross the placenta and have no risk on the fetus for bleeding or
teratogenicity [9, 20]. After CVT if patient want to get pregnant the risk is low but it is 9 cases
/1000 pregnancy. It seems low but compared to before CVT it is extremely high [22, 24].
The main limitations of this study are the retrospective character and being single centre
design. On the other hand, doing a prospective study will take long time since this study found
only one patient during twenty-three years. Added to that, doing multicentre study would give
better and more accurate results especially if it is done through national collaboration.
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Jayyar, L., Othman, B., & Othman, M. (2023). Cerebral Venous Thrombosis During Pregnancy; Tertiary Centre Experience. British Journal of
Healthcare and Medical Research, Vol - 10(6). 319-324.
URL: http://dx.doi.org/10.14738/bjhmr.106.16114.
CONCLUSIONS
First trimester poses important risk for developing CVT. In childbearing age CVT is a challenge
in diagnosis and management especially during pregnancy. The prevalence and incidence of
CVT in KSAMC is lower than the global results. This finding may provoke researchers in the
country to study CVT during pregnancy on the national level.
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