Acute Cerebrovascular Accident in Pregnancy Due to Hyperhomocysteinaemia Secondary to Vitamin B12 Deficiency: A Case Report

Abstract

Stroke in pregnancy is rare but is one of the leading causes of morbidity and mortality in developed countries. Pregnancy, as a prothrombotic state, acts as a precursor for stroke. Preeclampsia, eclampsia, amniotic fluid embolism, hypertension, diabetes, and many other factors predispose to the development of stroke. Endothelial cell injury leading to arteriosclerosis, causing a stroke, has been associated with raised homocysteine levels. Hereby, the authors present a case of a 26-year-old Gravida 3 Pregnancy 1 Live 1 Abortion 1 (G3P1L1A1) at 35 weeks gestation with a cephalic presentation who complained of a headache for two days, sudden onset of weakness in the right upper limb and lower limb with an inability to walk without support and inability to speak since 12 hours, associated with one episode of vomiting. Magnetic Resonance Imaging (MRI) brain showed acute infarcts in the left fronto-parietal lobes and capsule region with haemorrhagic transformation in the left frontal lobe. Serum vitamin B12 measured by Electroluminescence Assay (ECLA) was found to be low at 113pg/mL (normal range -191-771pg/mL). Serum homocysteine levels measured by enzymatic method were elevated at 46 umol/L (normal range 3-18 umol/L). A diagnosis at 34 weeks of pregnancy with acute cerebrovascular accident with right hemiparesis with Broca’s aphasia due to hyperhomocysteinaemia secondary to vitamin B12 deficiency was made. Prompt diagnosis and treatment are known to decrease morbidity in women with cerebrovascular accidents. MRI brain with venogram is known to be the gold standard procedure in diagnosing stroke. Thrombolytic therapy has proven beneficial in the treatment of the disease and in preventing its progression. Prenatal and natal supplementation with folic acid/vitamin B12 in the first trimester of pregnancy prevents Vitamin B12 deficiency and raised homocysteine levels in the maternal serum, thereby decreasing the incidence of stroke.