Stroke in Pregnancy and Puerperium

Karjalainen, Liisa; Tikkanen, Minna; Rantanen, Kirsi; Aarnio, Karoliina; Korhonen, Aino; Richardt, Anna; Laivuori, Hannele; Gissler, Mika; Ijäs, Petra

doi:10.1212/wnl.0000000000011990

Cited by 37 publications

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“…The literature search identified eight studies. Three were from the Nationwide Inpatient Sample in the US ( 12 – 14 ), two were national healthcare register-based studies from Canada ( 15 ), and one each were from the UK ( 18 ), Sweden ( 19 ), and Finland ( 16 ). One study on temporal trends of severe maternal morbidity in Canada ( 20 ) was excluded as it analyzed the same dataset and time period as the study specifically focused on PAS ( 15 ).…”

Section: Incidence Trends Of Pregnancy-associated Strokementioning

confidence: 99%

“…Nevertheless, the incidence was lower than in the earlier studies from the US. A recent Finnish population-based study that covered a 30-year time period from 1987 to 2016 revealed an increasing incidence of PAS from 11.1 to 25.2 per 100 000 deliveries from 1987–91 to 2012–16 ( p < 0.0001) ( 16 ). Among stroke subtypes, the rising trend was significant for ischemic stroke and CVT but not for subarachnoid hemorrhage (SAH) or ICH.…”

Section: Incidence Trends Of Pregnancy-associated Strokementioning

confidence: 99%

“…Stroke during pregnancy and postpartum often arises from an adverse interaction between normal physiological changes related to pregnancy, complications of pregnancy or delivery, and baseline characteristics of the pregnant woman ( Figure 1 ) ( 6 , 14 , 16 , 21 , 22 ). Lifestyle factors and diseases of the pregnant woman that increase stroke risk include substance abuse (smoking, alcohol, illicit drugs), obesity, diabetes, dyslipidaemia, chronic hypertension, heart disease, migraine, antiphospholipid syndrome and systemic lupus erythematous, coagulopathy, certain genetic traits (sickle cell disease, CADASIL), and cerebrovascular malformations (aneurysms, arteriovenous malformations, moyamoya disease) ( 6 , 14 , 16 , 21 , 22 ). Among demographic factors, advanced age and African-American race are associated with an increased risk of PAS ( 14 – 16 , 21 ).…”

Section: Trends In the Prevalence Of Risk Factors Of Pregnancy-associ...mentioning

confidence: 99%

“…Lifestyle factors and diseases of the pregnant woman that increase stroke risk include substance abuse (smoking, alcohol, illicit drugs), obesity, diabetes, dyslipidaemia, chronic hypertension, heart disease, migraine, antiphospholipid syndrome and systemic lupus erythematous, coagulopathy, certain genetic traits (sickle cell disease, CADASIL), and cerebrovascular malformations (aneurysms, arteriovenous malformations, moyamoya disease) ( 6 , 14 , 16 , 21 , 22 ). Among demographic factors, advanced age and African-American race are associated with an increased risk of PAS ( 14 – 16 , 21 ). Complications of pregnancy and delivery, such as hyperemesis gravidarum, post-partum hemorrhage and infection, and Cesarean section, may precipitate stroke by exaggerating a prothrombotic state and fluid-electrolyte-acid-base disturbances ( 21 , 22 ).…”

Section: Trends In the Prevalence Of Risk Factors Of Pregnancy-associ...mentioning

confidence: 99%

“…Age is the most important non-modifiable risk factor for stroke and also increases the risk of stroke in pregnancy. In the Finnish population-based study, the incidence was three times higher in women >40 years than in those between 20 and 24 years ( 16 ). In many middle- and high-income countries, the mean maternal age at first birth has increased by several years.…”

Section: Trends In the Prevalence Of Risk Factors Of Pregnancy-associ...mentioning

confidence: 99%

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Trends in the Incidence and Risk Factors of Pregnancy-Associated Stroke

Ijäs

2022

Front. Neurol.

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Pregnancy is a female-specific risk factor for stroke. Although pregnancy-associated stroke (PAS) is a rare event, PAS leads to considerable maternal mortality and morbidity. It is estimated that 7.7–15% of all maternal deaths worldwide are caused by stroke and 30–50% of surviving women are left with persistent neurological deficits. During last decade, several studies have reported an increasing incidence of PAS. The objective of this review is to summarize studies on time trends of PAS in relation to trends in the prevalence of stroke risk factors in pregnant women. Seven retrospective national healthcare register-based cohort studies from the US, Canada, UK, Sweden, and Finland were identified. Five studies from the US, Canada, and Finland reported an increasing trend of PAS. Potential biases include more sensitive diagnostics and improved stroke awareness among pregnant women and professionals toward the end of the study period. However, the concurrent increase in the prevalence of several stroke risk factors among pregnant women, particularly advanced age, hypertensive disorders of pregnancy, diabetes, and obesity, indicate that the findings are likely robust and should be considered seriously. To reduce stroke in pregnancy, increased awareness among all medical specialties and pregnant women on the importance of risk-factor management during pregnancy and stroke symptoms is necessary. Important preventive measures include counseling for smoking cessation and substance abuse, treatment of hypertensive disorders of pregnancy, use of aspirin in women at high risk for developing preeclampsia, and antithrombotic medication and pregnancy surveillance for women with high-risk conditions. Epidemiological data from countries with a high risk-factor burden are largely missing. National and international registries and prospective studies are needed to increase knowledge on the mechanisms, risk factors, management, and future implications for the health of women who experience this rare but devastating complication of pregnancy.

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Section: Incidence Trends Of Pregnancy-associated Strokementioning

confidence: 99%

Section: Incidence Trends Of Pregnancy-associated Strokementioning

confidence: 99%

Section: Trends In the Prevalence Of Risk Factors Of Pregnancy-associ...mentioning

confidence: 99%

Section: Trends In the Prevalence Of Risk Factors Of Pregnancy-associ...mentioning

confidence: 99%

Section: Trends In the Prevalence Of Risk Factors Of Pregnancy-associ...mentioning

confidence: 99%

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Trends in the Incidence and Risk Factors of Pregnancy-Associated Stroke

Ijäs

2022

Front. Neurol.

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

et al. 2023

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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.

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Risk factors and outcomes in people with stroke associated with pregnancy: A retrospective single‐center cohort

Bartal

Clifford

Bentum

et al. 2022

Intl J Gynecology & Obste

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Objective To describe timing, antecedent events, and outcomes in pregnancy‐related stroke (PAS). Methods Retrospective single‐center cohort of all PAS within 42 days of delivery from September 2010 to May 2021. Data were abstracted from medical records. Results Among 51 500 births, we identified 91 cases of PAS, with a stroke rate of 177 per 100 000 births. Of all PAS, 62% (n = 56) were hemorrhagic, 56% (n = 51) occurred postpartum, 49% (n = 45) occurred in patients with hypertensive disorders of pregnancy (HDP), and 36% (n = 33) had surgical interventions. There were nine deaths, with a case fatality rate of 9.9%. Of the survivors (n = 82), 37 (45.1%) had residual deficits. Patients with HDP were more likely to have a postpartum stroke than those without HDP (crude relative risk 1.72, 95% confidence interval 1.16–2.55). Among patients with HDP, 89% had at least one severe range blood pressure (BP), with a peak systolic BP of 187.8 ± 27.9 mm Hg and a peak diastolic BP of 109.4 ± 18.4 mm Hg. There was no difference in presenting symptoms (P = 0.120), residual deficits (P = 0.609), or mortality (P = 0.739) between those with or without HDP. Conclusions At a referral hospital, PAS was uncommon but was associated with a high mortality rate. An improved understanding of the modifiable risk factors is warranted to avert the sequelae of PAS.

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Stroke in Pregnancy and Puerperium

Cited by 37 publications

References 39 publications

Trends in the Incidence and Risk Factors of Pregnancy-Associated Stroke

Trends in the Incidence and Risk Factors of Pregnancy-Associated Stroke

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

Risk factors and outcomes in people with stroke associated with pregnancy: A retrospective single‐center cohort

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