Abstract

Fibromuscular dysplasia is a non-inflammatory angiopathy that occurs predominately in young to middle-aged females,2 affecting most commonly the renal (60-75%) and cerviocranial (25-30%) arteries.2 During pregnancy and the puerperium the incidence of stroke can increase threefold to thirteen fold.3

Only isolated case reports describe carotid artery dissections in post partum women following caesarean section.4 5

This case report describes the dilemmas in the antenatal treatment of a patient with a previous middle cerebral artery infarction and carotid artery dissection with underlying fibromuscular dysplasia on life long Aspirin. A recent MRI reported an abnormal right Internal Carotid Artery with distal ectasia and pseudo-aneurysm.

The key areas of management dilemmas included antenatal as well as intrapartum anticoagulation, mode of delivery and recurrent stroke.

There is no documented evidence that the uterine artery is involved in fibromuscular dysplasia and thus fetal growth and well-being should not be compromised.

Expert opinion was sought from stroke physicians, haematologists and neurologists regarding anticoagulation with varying advice given. We commenced the patient on Heparin with her Aspirin at 18 weeks gestation. There is however inadequate evidence in the literature regarding the definitive thromboprophalaxis in pregnancy in such situations.6

She was scheduled for an elective caesarean section, thereby avoiding the “Valsalva manoeuvre” induced risk of stroke in active 2^nd stage. However, the patient went into spontaneous preterm labour at 34 weeks and had a Neville-Barnes Forceps with no maternal effort. She received 6 weeks of postnatal heparin and continues with her regular daily Aspirin.