Comparison of Stroke Recurrence, Cardiovascular Events, and Death Among Patients With Pregnancy-Associated vs Non–Pregnancy-Associated Stroke

Abstract

ImportanceWomen with pregnancy-associated stroke might have different risks of stroke recurrence, including during subsequent pregnancies, and other cardiovascular events due to pregnancy-specific stroke risk factors, such as gestational hypertension, preeclampsia, or gestational diabetes.ObjectiveTo estimate the rate of stroke recurrence, cardiovascular hospitalization, and death in women with pregnancy-associated stroke compared with women with non–pregnancy-associated stroke.Design, Setting, and ParticipantsThis cohort study included all women aged 15 to 49 years in France who were affiliated with the general scheme of French health care insurance (94% of women) and had a first hospitalization for stroke between January 1, 2010, and December 31, 2018. Women were followed up until December 31, 2020, with the registration of stroke recurrence, hospitalization for cardiovascular conditions, and death. Data were from the French health care database Système National des Données de Santé. Statistical analyses were conducted between December 2021 and September 2022.ExposurePregnancy status at the time of stroke.Main Outcomes and MeasuresPoisson regressions were used to estimate incidence rates of these events with 95% CIs. We used Cox proportional hazards regression models to estimate the hazard ratios (HRs) of each event during the follow-up for women with a pregnancy-associated stroke vs women with a non–pregnancy-associated stroke.ResultsAmong women aged between 15 and 49 years between 2010 and 2018 and living in France, 1204 had a pregnancy-associated stroke at a mean (SD) age of 31.5 (5.8) years, and 31 697 had a non–pregnancy-associated stroke at a mean age of 39.6 (8.2) years. Among the 1204 women with a pregnancy-associated stroke, the incidence rate was 11.4 (95% CI, 9.0-14.3) per 1000 person-years, with 2 recurrent events during a subsequent pregnancy. Compared with women with non–pregnancy-associated stroke, women with pregnancy-associated stroke had lower risks of ischemic stroke (adjusted HR, 0.53; 95% CI, 0.36-0.77), cardiovascular events (adjusted HR, 0.58; 95% CI, 0.49-0.69), and death (adjusted HR, 0.42; 95% CI, 0.22-0.79). In contrast, the risk of recurrent intracerebral hemorrhage and cerebral venous thrombosis did not differ significantly, whereas the risks of venous thromboembolism (HR, 2.02; 95% CI, 1.14-3.58) and acute coronary syndrome with ST-segment elevation (HR, 3.93; 95% CI, 1.10-14.0) were increased.Conclusions and RelevanceIn this cohort study, although the risks of ischemic stroke, overall cardiovascular events, and mortality were lower after a pregnancy-associated stroke than after a non–pregnancy-associated stroke, the risks of venous thromboembolism and acute coronary syndrome with ST-segment elevation were higher. Recurrent stroke during a subsequent pregnancy remained rare.

Long-Term Mortality, Recovery, and Vocational Status After a Maternal Stroke

“…As 92.4% of controls and 92.3% of cases were under 60 years of age in 2016, most of the women were on pension due to disease or disability. Data on the long-term morbidity of patients with a maternal stroke are limited to subsequent cardiovascular morbidity described by Béjot et al 13 This French study found that a stroke recurred in 6.3% of women with a prior maternal stroke and that 13.6% were hospitalized for another cardiovascular event. 13 The risk of both stroke recurrence and other cardiovascular diseases was lower in comparison with that of matched women with a history of a stroke not associated with pregnancy or puerperium.…”

“…Data on the long-term morbidity of patients with a maternal stroke are limited to subsequent cardiovascular morbidity described by Béjot et al 13 This French study found that a stroke recurred in 6.3% of women with a prior maternal stroke and that 13.6% were hospitalized for another cardiovascular event. 13 The risk of both stroke recurrence and other cardiovascular diseases was lower in comparison with that of matched women with a history of a stroke not associated with pregnancy or puerperium. 13 Regardless of a longer follow-up in our study, the stroke recurrence was similar to that reported in France.…”

“…12 During the past year, these have been studied on 3 cohorts in diverse settings. [13][14][15] The long-term mortality has been described in a French cohort and in a Chinese cohort. In the French cohort, 4.1% of women with pregnancy-associated IS, ICH, SAH, or CVT, surviving the initial stroke admission, died during the follow-up at a median of 5.5 years.…”

“…The completeness and accuracy of both registers are rated from good to satisfactory, and the coverage of the MBR is estimated to be 100%. 13,14 We obtained hospital charts for all register-identified cases of a maternal stroke to verify the temporal connection of the stroke and pregnancy (conception-12 weeks postpartum). The type of stroke, recovery, and subsequent morbidity were retrieved from the hospital charts.…”

“…5 Data on the longterm prognosis after a maternal stroke have been lacking until recently, 12 when 3 studies explored long-term outcomes including mortality. [13][14][15] These studies with approximately a 5-year follow-up report long-term mortality after a maternal IS, CVT, or HS to be 4%-17% and 66% of women with a hemorrhagic stroke (HS) to recover to be independent in their daily activities. However, these studies lack comparison with matched controls; there are no studies on the long-term recovery after a maternal IS or CVT or changes in the vocational (working) activities after a maternal stroke.…”