Abstract 4142422: Heart of the Mystery: Unveiling PFO's Role in Cryptogenic Stroke During Pregnancy

Background: Patent Foramen Ovale (PFO) is a common cardiac anomaly that persists into adulthood in approximately 25% of the population. Although often clinically silent, PFOs can lead to complications in pregnancy, such as paradoxical strokes. Here, we present a case of a pregnant patient with a cryptogenic stroke attributed to PFO, highlighting the complex decision-making involved in her management. Case Description: A 37-year-old woman, G2P1001 at 9 weeks gestation, presented to her ophthalmologist with 2 days of decreased vision in her left eye. She was diagnosed with branch retinal artery occlusion and underwent laser embolization. Subsequently, she was sent to the hospital for an expedited work-up. The patient was started on aspirin upon presentation. MRI of the brain and MR angiography of the head and neck were unremarkable, and lower extremity duplex studies were normal. Transthoracic echocardiography revealed a PFO with a mild interatrial septal aneurysm. Hypercoagulable work-up revealed low protein S free antigen and a positive anticardiolipin IgM, both difficult to interpret during pregnancy. Given the high-risk morphology of the PFO, there was concern for a paradoxical stroke. The RoPE Score was calculated to be 9, indicating an 88% chance that the stroke was due to the PFO. She was then initiated on enoxaparin daily and discharged with outpatient follow-up. The rest of the coagulable work-up was unrevealing. Repeat protein S levels were still low but considered normal for pregnancy. It was determined that the patient did not have genetic thrombophilia but was hypercoagulable due to pregnancy. After interdisciplinary discussions, the patient underwent PFO closure at 15 weeks gestation. Post-procedure, she was transitioned to aspirin and a three-month course of clopidogrel. Enoxaparin was resumed post-clopidogrel up until one month before delivery, when subcutaneous heparin was initiated. She successfully delivered at 39 weeks, after which enoxaparin was resumed and continued for 6 weeks postpartum. Repeat protein S testing 12 weeks postpartum was normal, and aspirin was discontinued. Conclusion: This case of a pregnant patient with stroke highlights the importance of prompt screening for PFO and tailored management to prevent recurrence. It underscores the importance of thorough evaluation and interdisciplinary collaboration in treatment planning and demonstrates the safety and effectiveness of PFO closure during pregnancy.