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Roeder HJ, Lopez JR, Miller EC. Ischemic stroke and cerebral venous sinus thrombosis in pregnancy. HANDBOOK OF CLINICAL NEUROLOGY 2020; 172:3-31. [PMID: 32768092 PMCID: PMC7528571 DOI: 10.1016/b978-0-444-64240-0.00001-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Maternal ischemic stroke and cerebral venous sinus thrombosis (CVST) are dreaded complications of pregnancy and major contributors to maternal disability and mortality. This chapter summarizes the incidence and risk factors for maternal arterial ischemic stroke (AIS) and CVST and discusses the pathophysiology of maternal AIS and CVST. The diagnosis, treatment, and secondary preventive strategies for maternal stroke are also reviewed. Special populations at high risk of maternal stroke, including women with moyamoya disease, sickle cell disease, HIV, thrombophilia, and genetic cerebrovascular disorders, are highlighted.
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Affiliation(s)
- Hannah J Roeder
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - Jean Rodriguez Lopez
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - Eliza C Miller
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States; NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, United States.
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Miller EC, Wen T, Elkind MSV, Friedman A, Boehme A. Infection During Delivery Hospitalization and Risk of Readmission for Postpartum Stroke. Stroke 2019; 50:2685-2691. [PMID: 31412756 PMCID: PMC6756953 DOI: 10.1161/strokeaha.119.025970] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Background and Purpose- Most cases of pregnancy-related ischemic stroke (IS) and hemorrhagic stroke (HS) occur postpartum. Infections have been identified as a trigger for strokes in young people and have been associated with strokes during delivery hospitalizations, but a temporal relationship has been difficult to establish. We hypothesized that infections diagnosed during a delivery admission would be associated with an increased risk of readmission for postpartum stroke. Methods- We conducted a retrospective cohort study using the Healthcare Cost and Utilization Project's National Readmissions Database from 2010 to 2014. Using weighted survey design Poisson regression analysis, we calculated adjusted risk ratios (aRR) and 95% CI for the association between infection during delivery admission and 30-day postpartum readmission for IS or HS. Results- Out of 17.2 million delivery admissions during the study period, 2128 were readmitted within 30 days for a stroke of any type. There were 1189 HS (intracerebral hemorrhage or subarachnoid hemorrhage) and 720 IS, and the remainder unspecified pregnancy-related stroke. Adjusting for age and comorbidities, women with delivery infections were at higher risk of readmission for postpartum stroke of any type (aRR, 1.19; 95% CI, 1.01-1.41). Women with infections had higher risk of readmission for postpartum IS (aRR, 1.75; 95% CI, 1.37-2.22), but not for postpartum HS (aRR, 0.96; 95% CI, 0.75-1.23). The effect of infection on 30-day IS readmission was larger in women without hypertensive disorders of pregnancy (aRR, 2.0; 95% CI, 1.55-2.69 in women without hypertensive disorders of pregnancy versus aRR, 1.47; 95% CI, 0.9-2.38 in women with hypertensive disorders of pregnancy, P value for interaction=0.09). Conclusions- Infection during delivery hospitalization was associated with increased risk of readmission for IS, but not HS, within 30 days postpartum, particularly in women without hypertensive disorders of pregnancy. Infection may play a role in triggering postpartum IS even in the absence of other risk factors.
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Affiliation(s)
- Eliza C. Miller
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons
| | - Timothy Wen
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons
| | - Mitchell S. V. Elkind
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons
- Department of Epidemiology, Columbia University Mailman School of Public Health
| | - Alexander Friedman
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons
| | - Amelia Boehme
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons
- Department of Epidemiology, Columbia University Mailman School of Public Health
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Abstract
PURPOSE OF THE REVIEW Maternal morbidity and mortality is rising in the USA, and maternal stroke is a major contributor. Here, we review the epidemiology, risk factors, and current recommendations for diagnosis and acute treatment of ischemic and hemorrhagic stroke during pregnancy and postpartum, focusing on recent evidence. RECENT FINDINGS The incidence of maternal stroke has risen in recent years, possibly due to increasing rates of hypertensive disorders of pregnancy. The risk of maternal stroke is highest in the peripartum and early postpartum period. Preeclampsia is highly associated with reversible cerebral vasoconstriction syndrome and posterior reversible encephalopathy syndrome and is also associated with long-term increased risk of stroke and vascular dementia. Hypertensive disorders of pregnancy, migraine, and infections are risk factors for maternal stroke. Limited data suggest that thrombolytics and endovascular reperfusion therapy are safe and effective in pregnant women with ischemic stroke, but few data are available regarding safety of thrombolytics in the postpartum period. New consensus guidelines are now available to assist with management of ischemic and hemorrhagic stroke in pregnancy. Many gaps remain in our understanding of maternal stroke. While risk factors have been identified, there are no prediction tools to help identify which women might be at highest risk for postpartum stroke and require closer monitoring. The risk of recurrent maternal stroke has not been adequately quantified, limiting clinicians' ability to counsel patients. The complex pathophysiology of preeclampsia and its effects on the cerebral vasculature require further targeted study. An increased focus on the prevention, recognition, and optimal treatment of maternal stroke will be critical to reducing maternal morbidity and mortality.
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Affiliation(s)
- Maria D Zambrano
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Eliza C Miller
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA.
- Neurological Institute of New York, 710 West 168th Street, 6th floor, New York, NY, 10032, USA.
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Dzakpasu S, Deb-Rinker P, Arbour L, Darling EK, Kramer MS, Liu S, Luo W, Murphy PA, Nelson C, Ray JG, Scott H, VandenHof M, Joseph KS. Severe Maternal Morbidity in Canada: Temporal Trends and Regional Variations, 2003-2016. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:1589-1598.e16. [PMID: 31060985 DOI: 10.1016/j.jogc.2019.02.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 02/06/2019] [Accepted: 02/07/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE This study sought to quantify temporal trends and provincial and territorial variations in severe maternal morbidity (SMM) in Canada. METHODS The study used data on all hospital deliveries in Canada (excluding Québec) from 2003 to 2016 to examine temporal trends and from 2012 to 2016 to study regional variations. SMM was identified using diagnosis and intervention codes. Contrasts among periods and regions were quantified using rate ratios (RRs) and 95% confidence intervals (CIs). Temporal changes were also assessed using chi-square tests for trend (Canadian Task Force Classification II-1). RESULTS The study population included 3 882 790 deliveries between 2003 and 2016 and 1 418 545 deliveries between 2012 and 2016. Severe hemorrhage rates increased from 44.8 in 2003 to 62.4 per 10 000 deliveries in 2012 (P for trend <0.0001) and then declined to 41.8 per 10 000 deliveries in 2016 (P for trend <0.0001). Maternal intensive care unit admission and sepsis rates decreased between 2003 and 2016, whereas rates of stroke, severe uterine rupture, hysterectomy, obstetric embolism, shock, and assisted ventilation increased. Rates of composite SMM in 2012-2016 were higher in Newfoundland and Labrador (RR 1.15; 95% CI 1.04-1.26), Nova Scotia (RR 1.11; 95% CI 1.03-1.19), New Brunswick (RR1.22; 95% CI 1.13-1.32), Manitoba (RR 1.09; 95% CI 1.03-1.15), Saskatchewan (RR 1.15; 95% CI 1.09-1.22), the Yukon (RR 1.74; 95% CI 1.35-2.25), and Nunavut (RR 1.76; 95% CI 1.46-2.11) compared with the rest of Canada, whereas rates were lower in Alberta and British Columbia. CONCLUSION This surveillance report helps inform clinical practice and public health policy for improving maternal health in Canada.
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Affiliation(s)
- Susie Dzakpasu
- Maternal and Infant Health Section, Public Health Agency of Canada, Ottawa, ON
| | - Paromita Deb-Rinker
- Maternal and Infant Health Section, Public Health Agency of Canada, Ottawa, ON
| | - Laura Arbour
- Department of Medical Genetics, University of British Columbia, Victoria, BC
| | | | - Michael S Kramer
- Department of Pediatrics, McGill University, Montréal, QC; Department of Epidemiology, Biostatistics, and Occupational Heath, McGill University, Montréal, QC
| | - Shiliang Liu
- Maternal and Infant Health Section, Public Health Agency of Canada, Ottawa, ON
| | - Wei Luo
- Maternal and Infant Health Section, Public Health Agency of Canada, Ottawa, ON
| | - Phil A Murphy
- Perinatal Program of Newfoundland and Labrador, St. John's, NL
| | - Chantal Nelson
- Maternal and Infant Health Section, Public Health Agency of Canada, Ottawa, ON
| | - Joel G Ray
- Department of Medicine, University of Toronto, Toronto, ON
| | - Heather Scott
- Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, NS
| | - Michiel VandenHof
- Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, NS
| | - K S Joseph
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC.
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