Vaginal Delivery Following Thrombolytic Therapy in the Third Trimester: A Case Report.

INTRODUCTION Stroke in pregnancy is a leading cause of maternal mortality, as it is estimated that 7.7-15% of all maternal deaths are due to stroke.1 Risk factors for stroke in women include the prothrombic state of pregnancy and pregnancy-associated complications including preeclampsia and eclampsia.2 Due to the commonly applied ethical barrier of including pregnant patients in randomized control trials, there are no clear guidelines for the management of pregnancy-associated stroke (PAS). Animal models suggest tissue plasminogen activator (tPA) does not cross the placenta, and a handful of case reports imply favorable outcomes with the use of tPA to treat ischemic infarcts in pregnancy.3-6 Despite the increased acceptance of tPA treatment in pregnancy, there remains a gap of knowledge pertaining to the timing of delivery in patients following tPA administration in the late third trimester. This is especially true in patients who have conditions in which immediate delivery is indicated, such as preeclampsia with severe features. The use of neuraxial anesthesia soon after tPA administration poses an additional clinical dilemma in which limited data exists. We present a patient with preeclampsia with severe features and persistent abnormal coagulation studies after tPA administration for presumed ischemic stroke who had an uncomplicated spontaneous vaginal delivery with epidural anesthesia.