Introduction
Patent foramen ovale (PFO) occurs in 25-30% of the general population. Stroke in the puerperium is a rare phenomenon (34 per 100,000 women)1. Paradoxical embolism may be more frequent in pregnancy due to the hypercoagulable state. Cases of stroke2,3 and myocardial infarction4,5 in conjunction with a patent foramen ovale in pregnancy and the peurperium have been reported.
Case Report
A 32 year old lady, Para3+2 presented eight days postnatally with symptoms of a transient episode of left sided facial and limb parathesia and dysphasia. Her antenatal course was complicated by a new diagnosis of hepatitis C at her booking visit. She was induced at 39 weeks gestation due to oligohydramnios and had a vaginal delivery. She had a CT brain which was normal, however a subsequent MRI brain showed a small right parietal lobe infarct. Carotid Doppler and lower limb Doppler studies were normal. An echocardiogram was performed which showed a small PFO, with an ejection fraction of 60-65%. A bubble study was performed which was positive with valsalva. She was started on aspirin 300mg once daily for 2 weeks, and shall remain on life-long aspirin 75mg. She has been seen at 2 and 6 weeks postnatally and is asymptomatic.
Discussion
This case represents transient symptoms of a parietal infarct in the postpartum period. Detection of PFO can be augmented by releasing a sustained Valsalva manoeuver while performing a Bubble study6. The Valsalva manoeuvre occurs during the second stage of labour causing the same right-to-left shunt to occur, allowing a paradoxical embolus to travel to the brain. A study by Komar et al, comparing symptomatic to asyptomatic patients with PFOs, showed that those who are sypmptomatic have larger diameter PFO (3.9mm +/- 1.4mm), longer tunnel length (overlap of septum primum and secundum) and a greater frequency of atrial septal aneurysm (55% vs 15%)7. The 2012 ACCP guidelines advise antiplatelet therapy in patients with cryptogenic stroke and PFO. Anticoagulation is indicated only in those with other risk factors such as a hypercoagulable state, or in the case of recurrent ischaemic events despite treatment with aspirin. Fortunately for this lady she suffered no residual neurological deficit and her prognosis is excellent.
B Anglim1, N Maher1, O Cunningham1, D Mulcahy2, J Harbison3, M O'Connell1
Departments of 1Obstetrics & Gynaecology, 2Cardiology, and 3Stroke Medicine, Coombe Women's Hospital, Dolphin’s Barn, Dublin 8
References
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3. Szydelko M, Kwolek A, Majka M. Stroke in young woman in the first day after delivery. Wiad Lek. 2006;59:280-4.
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