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Thrombolytic Pregnancy: Relative contraindication — individualised risk-benefit

Alteplase (tPA)

Brand names: Actilyse

Adult dose

Dose: 0.9 mg/kg (max 90 mg): 10% as IV bolus over 1 min, remainder as IV infusion over 60 min
Route: IV
Frequency: Single dose
Max: 90 mg
Ischaemic stroke only, within 4.5 hours of onset. Contraindicated if haemorrhagic stroke, recent surgery, active bleeding, BP >185/110 uncontrolled.

Paediatric dose

Route: IV
Frequency: Not licensed in children for ischaemic stroke
Max: N/A
Concentration: 1 mg/ml
Not routinely used in paediatric ischaemic stroke. Specialist guidance required.

Dose adjustments

Renal

No dose adjustment required.

Hepatic

Use with caution in severe hepatic impairment.

Clinical pearls

  • Door-to-needle time target: <60 minutes
  • Monitor BP every 15 min during and 2 hours after infusion
  • Hold antihypertensives before treatment unless BP >185/110
  • Stop infusion if severe headache, acute hypertension, or neurological deterioration

Contraindications

  • Haemorrhagic stroke
  • Recent intracranial surgery or trauma
  • Intracranial neoplasm
  • Uncontrolled hypertension (>185/110)
  • Active internal bleeding
  • Platelet count <100,000
  • Current anticoagulation with INR >1.7

Side effects

  • Haemorrhage (including intracranial)
  • Angioedema
  • Nausea and vomiting
  • Hypotension
  • Reperfusion arrhythmias

Interactions

  • Anticoagulants — increased bleeding risk
  • Antiplatelet agents — increased bleeding risk
  • NSAIDs — increased bleeding risk

Monitoring

  • BP every 15 min during infusion
  • Neurological status
  • Signs of bleeding
  • NIHSS score

Reference: BNFc; BNF; NICE NG128 Stroke and TIA. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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