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Risk of Stroke and Cerebrovascular Disease in Pregnancy
Study Questions:
What are the incidence, temporal trends, risk factors, and case fatality of stroke and cerebrovascular disease in pregnancy?
Methods:
Data from the Canadian Institute of Health Information (2003-2016) included all antepartum, peripartum, and postpartum hospitalizations and readmissions within 42 days of delivery in Canada (except Quebec).
Results:
There were 524 strokes among 3,907,262 deliveries (13.4 per 100,000): 58.6% were hemorrhagic strokes, 51.5% occurred in the postpartum period, and mortality was 7.4%. Between 2003-2004 and 2015-2016, stroke incidence increased from 10.8 per 100,000 to 16.6 per 100,000 (p = 0.002). Risk factors for stroke included: age ≥40 years (adjusted odds ratio [AOR], 1.7; 95% confidence interval [CI], 1.1-2.6), preeclampsia (AOR, 7.1; 95% CI, 5.3-9.6), eclampsia (AOR, 65.9; 95% CI, 43.6-99.6), congenital heart disease (AOR, 38.1; 95% CI, 22.1-65.8), connective tissue disorders (AOR, 12.6; 95% CI, 6.1-26.9), sepsis (AOR, 7.6; 95% CI, 3.6-16.2), severe postpartum hemorrhage (AOR, 4.7; 95% CI, 2.8-8.0), and thrombophilia (AOR, 4.2; 95% CI, 1.5-12.1).
Conclusions:
The incidence of stroke in pregnancy is increasing, especially in the postpartum period, and is strongly associated with hypertensive disorders of pregnancy (especially preeclampsia); thus, follow-up of patients with severe hypertension after delivery is required.
Perspective:
With rising awareness of the maternal morbidity and mortality in the United States, this study draws attention to the risk of stroke in the peripartum period, especially among women with hypertensive disorders. Increased awareness among physicians, as well as patients, is an important first step. Patients often do not have a postpartum visit until 6 weeks after delivery, but the American College of Obstetrics and Gynecology (ACOG) has recently recommended follow-up within the first 3 weeks postpartum. However, this still may not be sufficient for women at high risk for stroke. Additional education and counseling for patients and their families about the signs of stroke could be helpful. Women should be informed about monitoring their blood pressure at home and discharged from the hospital with a blood pressure cuff and close follow-up with the medical care team, perhaps via a nurse navigator. Future studies could also address the presence of arrhythmias and whether patients had been receiving anticoagulant or antiplatelet treatment.
Keywords: Blood Pressure, Connective Tissue, Eclampsia, Hypertension, Patient Care Team, Peripartum Period, Postpartum Hemorrhage, Postpartum Period, Pre-Eclampsia, Pregnancy, Primary Prevention, Risk Factors, Sepsis, Stroke, Thrombophilia, Vascular Diseases
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