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Vest T, Rantanen K, Verho L, Aarnio K, Korhonen A, Richardt A, Strbian D, Gissler M, Laivuori H, Tikkanen M, Ijäs P. Etiology of intracerebral hemorrhage during pregnancy or puerperium: A nationwide study. Eur J Neurol 2024; 31:e16012. [PMID: 37532682 PMCID: PMC11235636 DOI: 10.1111/ene.16012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND AND PURPOSE Intracerebral hemorrhage during pregnancy or puerperium (pICH) is one of the leading causes of maternal death worldwide. However, limited epidemiological data exist on the etiology and outcomes of pICH, which is required to guide prevention and treatment. METHODS A retrospective nationwide cohort study and a nested case-control study was performed in Finland 1987-2016. We identified women with incident pICH by linking the Medical Birth Register (MBR) and the Hospital Discharge Register (HDR). The clinical details were collected from patient records. Three matched controls with a pregnancy without ICH were selected for each case from the MBR. RESULTS In total, 49 pICH cases were identified. Half of these cases occurred during pregnancy, and the other half during peripartum and puerperium. Based on the SMASH-U (structural vascular lesion, medication, amyloid angiopathy, systemic disease, hypertension, undetermined) classification, 35.4% of the patients had a systemic disease, most commonly preeclampsia, eclampsia, or HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome; 31.3% had a structural vascular lesion; 31.3% had an undetermined etiology; and one patient (2.1%) had hypertension. The most important risk factor was hypertensive disorders of pregnancy (HDP; odds ratio = 3.83, 95% confidence interval = 1.60-9.15), occurring in 31% of the cases. Maternal mortality was 12.5%, and 20.9% of the surviving women had significant disability (modified Rankin Scale = 3-5) 3 months after the pICH. Women with systemic disease had the worst outcomes. CONCLUSIONS Even in a country with a comprehensive pregnancy surveillance system, the maternal mortality rate for pICH is high, and the sequelae are severe. Early recognition and treatment of the key risk factor, HDP, is crucial to help prevent this serious pregnancy complication.
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Affiliation(s)
- Teresa Vest
- Department of NeurologyUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Kirsi Rantanen
- Department of NeurologyUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Liisa Verho
- Department of Obstetrics and GynecologyUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Karoliina Aarnio
- Department of NeurologyUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Aino Korhonen
- Department of NeurologyUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Anna Richardt
- Department of NeurologyUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Daniel Strbian
- Department of NeurologyUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Mika Gissler
- Department of Knowledge BrokersFinnish Institute for Health and WelfareHelsinkiFinland
- Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
- Region StockholmAcademic Primary Health Care CentreStockholmSweden
| | - Hannele Laivuori
- Medical and Clinical GeneticsUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
- Institute for Molecular Medicine Finland, Helsinki Institute of Life ScienceUniversity of HelsinkiHelsinkiFinland
- Department of Obstetrics and GynecologyTampere University Hospital and Tampere University, Faculty of Medicine and Health Technology, Center for Child, Adolescent, and Maternal Health Research TampereTampereFinland
| | - Minna Tikkanen
- Department of Obstetrics and GynecologyUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Petra Ijäs
- Department of NeurologyUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
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Cagino K, Prabhu M, Sibai B. Is magnesium sulfate therapy warranted in all cases of late postpartum severe hypertension? A suggested approach to a clinical conundrum. Am J Obstet Gynecol 2023; 229:641-646. [PMID: 37467840 DOI: 10.1016/j.ajog.2023.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 07/21/2023]
Abstract
Magnesium sulfate reduces the risk for eclamptic seizures antepartum, intrapartum, and in the immediate postpartum period, however, there are no studies that have evaluated the benefits and risks of magnesium sulfate among women with late postpartum severe hypertension only. Juxtaposed on this clinical uncertainty is the increased incidence of severe hypertension owing to a rise in pregnancies complicated by advanced maternal age, obesity, chronic hypertension, diabetes, and recent protocols for intensive monitoring of blood pressure in the postpartum period. These factors have led to a significant increase in postpartum presentations for the evaluation and management of severe hypertension, in some cases leading to postpartum readmissions for administration of antihypertensive therapy and magnesium sulfate without data demonstrating clear clinical benefit. Postpartum readmissions can have several negative consequences, including interfering with early bonding with a newborn, breastfeeding, and use of scarce healthcare resources. In addition, magnesium sulfate is associated with risks for serious cardiorespiratory depression and bothersome side effects and can delay determining the optimal antihypertensive regimen, which is typically the most pressing clinical need during postpartum presentations of late-postpartum severe hypertension. Eclampsia that occurs more than 48 hours after delivery is rare (constitutes 16% of all cases of eclampsia) and is most commonly preceded by headaches or other cerebral symptoms. In this commentary, we propose an approach to evaluating and managing patients with late postpartum severe hypertension aimed at identifying those women at highest risk for end-organ injury. We recommend that the short- and long-term focus for all patients with severe hypertension should be the optimal management of blood pressures with a goal of close outpatient monitoring when logistically feasible and clinically appropriate. We suggest reserving magnesium sulfate therapy for the subset of patients with neurologic symptoms who may be at highest risk for an eclamptic seizure.
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Affiliation(s)
- Kristen Cagino
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at Houston, Houston, TX.
| | - Malavika Prabhu
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA
| | - Baha Sibai
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at Houston, Houston, TX
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Yajima H, Miyawaki S, Sayama S, Kumasawa K, Ikemura M, Imai H, Hongo H, Hirano Y, Ishigami D, Torazawa S, Kiyofuji S, Koizumi S, Saito N. Hypertensive disorders of pregnancy in moyamoya disease: A single institution experience. J Stroke Cerebrovasc Dis 2023; 32:107377. [PMID: 37742384 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/21/2023] [Accepted: 09/16/2023] [Indexed: 09/26/2023] Open
Abstract
OBJECTIVE The characteristics of pregnancy and delivery in patients with moyamoya disease (MMD) remain unclear. We retrospectively investigated perinatal outcomes in patients with MMD to evaluate the risks associated to this condition. MATERIALS AND METHODS Clinical data of women with MMD who delivered at the University of Tokyo Hospital between 2000 and 2021 were collected. Maternal characteristics including genetic data, obstetric complications, method of delivery and anesthesia, neonatal outcomes, neurological events during pregnancy, delivery, and postpartum course, were reviewed. RESULTS Thirteen pregnancies with MMD were identified. The median maternal age was 30 years. The initial clinical symptoms were identified as transient ischemic attack, infarction, and headache. Eight patients had a history of bypass surgery. The median gestational age at delivery was 37 weeks. DNA samples were collected from five patients, responsible for six pregnancies. Of these six cases, five had the RNF213 c.14429G > A (p.Arg4810Lys) heterozygous variant. Of the 13 pregnancies, seven had hypertensive disorder of pregnancy (HDP). Additionally, three of five pregnancy cases with RNF213 p.Arg4810Lys heterozygous variant presented with HDP. Nine patients underwent cesarean section, and four delivered vaginally with epidural anesthesia. One case of ischemic stroke was confirmed during the postpartum period. Regarding newborns, neither Apgar scores lower than 7 nor neonatal intensive care unit admissions were reported. CONCLUSIONS This study suggests that the frequency of HDP is higher in patients with MMD compared to those with normal pregnancies. Strict blood pressure control should be performed in patients with MMD during pregnancy and postpartum period.
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Affiliation(s)
- Hirohisa Yajima
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Tokyo 113-8655, Japan
| | - Satoru Miyawaki
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Tokyo 113-8655, Japan.
| | - Seisuke Sayama
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Keiichi Kumasawa
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masako Ikemura
- Department of Pathology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hideaki Imai
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Tokyo 113-8655, Japan; Department of Neurosurgery, Japan Community Healthcare Organization Tokyo Shinjuku Medical Center, Shinjuku-ku, Tokyo, Japan
| | - Hiroki Hongo
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Tokyo 113-8655, Japan
| | - Yudai Hirano
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Tokyo 113-8655, Japan
| | - Daiichiro Ishigami
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Tokyo 113-8655, Japan
| | - Seiei Torazawa
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Tokyo 113-8655, Japan
| | - Satoshi Kiyofuji
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Tokyo 113-8655, Japan
| | - Satoshi Koizumi
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Tokyo 113-8655, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Tokyo 113-8655, Japan
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Beckett AG, McFadden MD, Warrington JP. Preeclampsia history and postpartum risk of cerebrovascular disease and cognitive impairment: Potential mechanisms. Front Physiol 2023; 14:1141002. [PMID: 37064920 PMCID: PMC10102351 DOI: 10.3389/fphys.2023.1141002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/22/2023] [Indexed: 04/03/2023] Open
Abstract
Hypertensive disorders of pregnancy such as preeclampsia, eclampsia, superimposed preeclampsia, and gestational hypertension are major causes of fetal and maternal morbidity and mortality. Women with a history of hypertensive pregnancy disorders have increased risk of stroke and cognitive impairments later in life. Moreover, women with a history of preeclampsia have increased risk of mortality from diseases including stroke, Alzheimer's disease, and cardiovascular disease. The underlying pathophysiological mechanisms are currently not fully known. Here, we present clinical, epidemiological, and preclinical studies focused on evaluating the long-term cerebrovascular and cognitive dysfunction that affect women with a history of hypertensive pregnancy disorders and discuss potential underlying pathophysiological mechanisms.
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Affiliation(s)
- Ashtin G. Beckett
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, MS, United States
| | - Mia D. McFadden
- School of Medicine, University of Mississippi Medical Center, Jackson, MS, United States
| | - Junie P. Warrington
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS, United States
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Abstract
Women face a disproportionate burden of stroke mortality and disability. Biologic sex and sociocultural gender both contribute to differences in stroke risk factors, assessment, treatment, and outcomes. There are substantial differences in the strength of association of stroke risk factors, as well as female-specific risk factors. Moreover, there are differences in presentation, response to treatment, and stroke outcomes in women. This review outlines current knowledge of impact of sex and gender on stroke, as well as delineates research gaps and areas for future inquiry.
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Affiliation(s)
- Kathryn M. Rexrode
- Division of Women’s Health, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Tracy E. Madsen
- Division of Sex and Gender in Emergency Medicine, Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI; Department of Epidemiology, Brown University School of Public Health, Providence RI
| | - Amy Y. X. Yu
- Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Cheryl Carcel
- Neurology Program, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Judith H. Lichtman
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Eliza C. Miller
- Division of Stroke and Cerebrovascular Disease, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
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6
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Miller EC. Maternal Stroke Associated With Pregnancy. Continuum (Minneap Minn) 2022; 28:93-121. [PMID: 35133313 PMCID: PMC10101187 DOI: 10.1212/con.0000000000001078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article summarizes current knowledge of the epidemiology, pathophysiology, prevention, and treatment of cerebrovascular disease in pregnant and postpartum women. RECENT FINDINGS Stroke is a leading cause of maternal morbidity and mortality, and most fatal strokes are preventable. Adaptive physiologic changes of pregnancy, including hemodynamic changes, venous stasis, hypercoagulability, and immunomodulation, contribute to increased maternal stroke risk. The highest-risk time period for maternal stroke is the immediate postpartum period. Migraine and hypertensive disorders of pregnancy, including gestational hypertension and preeclampsia, are major risk factors for maternal stroke. Adverse pregnancy outcomes, including gestational hypertension, preeclampsia, preterm delivery, and fetal growth restriction, are important risk factors for cerebrovascular disease later in life. SUMMARY Many catastrophic maternal strokes could be avoided with targeted prevention efforts, early recognition of warning signs, and rapid evaluation of neurologic symptoms. Neurologists play a central role in the care of pregnant patients with cerebrovascular disease, whether acute or chronic, and should be familiar with the unique and complex physiology of pregnancy and its complications, particularly hypertensive disorders of pregnancy.
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Saitou T, Watanabe K, Iwasaki A, Matsushita H, Wakatsuki A. Intracranial hemorrhage in pregnant women with hypertensive disorders of pregnancy. HYPERTENSION RESEARCH IN PREGNANCY 2022. [DOI: 10.14390/jsshp.hrp2022-005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Takuya Saitou
- Department of Obstetrics and Gynecology, Aichi Medical University School of Medicine
| | - Kazushi Watanabe
- Department of Obstetrics and Gynecology, Aichi Medical University School of Medicine
| | - Ai Iwasaki
- Department of Obstetrics and Gynecology, Aichi Medical University School of Medicine
| | - Hiroshi Matsushita
- Department of Obstetrics and Gynecology, Aichi Medical University School of Medicine
| | - Akihiko Wakatsuki
- Department of Obstetrics and Gynecology, Aichi Medical University School of Medicine
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Liew J, Feghali J, Huang J. Intracerebral and subarachnoid hemorrhage in pregnancy. HANDBOOK OF CLINICAL NEUROLOGY 2021; 172:33-50. [PMID: 32768093 DOI: 10.1016/b978-0-444-64240-0.00002-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Maternal stroke occurs in around 34 out of every 100,000 deliveries and is responsible for around 5%-12% of all maternal deaths. It is most commonly hemorrhagic, and women are at highest risk for developing pregnancy-related hemorrhage during the early postpartum period through 6 weeks following the delivery. The most common causes of hemorrhagic stroke in pregnant patients are arteriovenous malformations and cerebral aneurysms. Management is similar to that for acute hemorrhagic stroke in the nonpregnant population with standard use of computed tomography and judicious utilization of intracranial vessel imaging and contrast. The optimal delivery method is evaluated on a case-by-case basis, and cesarean delivery is not always required. As most current studies are limited by retrospective design, relatively small sample sizes, and heterogeneous study term definitions, strong and comprehensive evidence-based guidelines on the management of acute hemorrhagic stroke in pregnant patients are still lacking. In the future, multicenter registries and prospective studies with uniform definitions will help improve management strategies in this complex patient population.
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Affiliation(s)
- Jason Liew
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - James Feghali
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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Enomoto N, Tanaka H, Katsuragi S, Hayata E, Hasegawa J, Nakata M, Takahashi JC, Sekizawa A, Ishiwata I, Ikeda T. Pregnancy-associated hemorrhagic stroke: A nationwide survey in Japan. J Obstet Gynaecol Res 2021; 47:2066-2075. [PMID: 33821513 DOI: 10.1111/jog.14786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 02/10/2021] [Accepted: 03/09/2021] [Indexed: 11/29/2022]
Abstract
AIM The number of maternal deaths due to pregnancy-associated hemorrhagic stroke has not decreased despite a gradual decrease of maternal death in Japan. This study aimed to clarify the risk factors of hypertensive disorders of pregnancy-associated hemorrhagic stroke. METHODS This retrospective study analyzed pregnancy-associated hemorrhagic stroke patients with hypertensive disorders of pregnancy between 2013 and 2017 among 407 Japanese maternal and perinatal centers. Patients were divided into good or poor outcome groups and their maternal backgrounds and neonatal prognoses were compared. RESULTS We analyzed 61 cases, including 41 survival and 20 death cases, obtained from a secondary survey. Among the 61 hemorrhagic stroke cases, 62% were related to hypertensive disorders. Hypertensive disorders of pregnancy were observed in 75% of death cases. Use of MgSO4 or antihypertensive medication did not differ between the poor and good outcomes groups. In cases with antepartum onset of hypertensive disorders of pregnancy, outcomes were poor in 12 and good in 6 cases. Nine patients with poor outcomes and one with a good outcome had hypertension at the outpatient department without systemic evaluation (p = 0.043). Six poor outcomes patients and one good outcome spent more than 1 day from diagnosis at an outpatient clinic. Neurosurgery was performed in 11 poor outcome patients. CONCLUSION Pregnant women who present with a hypertensive disorder at an outpatient clinic probably need to undergo blood tests and careful observation. Delayed systemic evaluation and intensive care for only a few days may result in the development of hemorrhage.
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Affiliation(s)
- Naosuke Enomoto
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Tsu, Mie, Japan
| | - Hiroaki Tanaka
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Tsu, Mie, Japan
| | - Shinji Katsuragi
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Tsu, Mie, Japan
| | - Eijiro Hayata
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Junichi Hasegawa
- Department of Obstetrics and Gynecology, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Masahiko Nakata
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Jun C Takahashi
- Department of Neurosurgery, Kindai University Faculty of Medicine, Osaka, Japan
| | - Akihiko Sekizawa
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Isamu Ishiwata
- Department of Obstetrics and Gynecology, Ishiwata Obstetrics and Gynecology Hospital, Ibaraki, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Tsu, Mie, Japan
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Tanaka H, Kamiya CA, Horiuchi C, Morisaki H, Tanaka K, Katsuragi S, Hayata E, Hasegawa J, Nakata M, Sekizawa A, Ishiwata I, Ikeda T. Aortic dissection during pregnancy and puerperium: A Japanese nationwide survey. J Obstet Gynaecol Res 2021; 47:1265-1271. [PMID: 33480070 DOI: 10.1111/jog.14657] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 12/11/2020] [Accepted: 12/26/2020] [Indexed: 11/29/2022]
Abstract
AIM This study aimed to characterize the incidence and clinical significance of pregnancy-related aortic dissection using a large-scale survey in Japan. METHODS A questionnaire requesting the detailed information included in the clinical charts of pregnancy-related aortic dissection cases (without any personally identifying information) was designed between 2013 and 2017 and administered to 407 perinatal centers in Japan. The response rate was 70.5%. Seventeen cases of pregnancy-related aortic dissection were identified. RESULTS Maternal death due to aortic dissection was observed in nine patients (56.2%) while seven survived (43.8%). Dissection occurred during the postpartum period in 10 cases (62.5%), the third trimester in 4 (25.0%), labor in 1 (6.2%), and the second trimester in 1 (6.2%). The most common underlying diseases were: Marfan syndrome (25.0%), Loeys-Dietz syndrome (6.2%), hypertension (6.2%), and Takayasu aortitis (6.2%). Stanford type A aortic dissection was associated with maternal death during both pregnancy and the postpartum period. However, deceased patients showed lower rates of pre-diagnosed connective tissue disease than did survivors. CONCLUSIONS The mortality rate of aortic dissection that occurred during pregnancy or postnatal periods was more than 50%. Aortic dissection occurred more frequently in the postnatal period than during pregnancy, and less frequently in women previously diagnosed with connective tissue disease than in women without any medical history of aortic disorders. If symptoms suggestive of aortic dissection, such as severe back pain, are observed, even after the end of pregnancy, exhaustive diagnostic examinations should be carried out.
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Affiliation(s)
- Hiroaki Tanaka
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Mie, Japan
| | - Chizuko A Kamiya
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Chinami Horiuchi
- Department of Obstetrics and Gynecology, Sakakibara Heart Institute, Tokyo, Japan
| | - Hiroko Morisaki
- Department of Medical Genetics, Sakakibara Heart Institute, Tokyo, Japan
| | - Kayo Tanaka
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Mie, Japan
| | - Shinji Katsuragi
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Mie, Japan
| | - Eijiro Hayata
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Junichi Hasegawa
- Department of Obstetrics and Gynecology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Masahiko Nakata
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Akihiko Sekizawa
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Isamu Ishiwata
- Department of Obstetrics and Gynecology, Ishiwata Obstetrics and Gynecology Hospital, Ibaraki, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Mie, Japan
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Esmaeilzadeh M, Uksul N, Hong B, von Kaisenberg C, Scheinichen D, Lang JM, Hermann EJ, Hillemanns P, Krauss JK. Intracranial emergencies during pregnancy requiring urgent neurosurgical treatment. Clin Neurol Neurosurg 2020; 195:105905. [PMID: 32428795 DOI: 10.1016/j.clineuro.2020.105905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 04/19/2020] [Accepted: 05/07/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Despite contemporary diagnostic and therapeutic techniques intracranial emergencies in the obstetric setting pose still a major challenge for the clinicians. There are limited guidelines and differing ethical views. Multidisciplinary teams are needed to support the pregnant woman in a way that she can deliver a viable and healthy child. The aim of the present study was to scrutinize the management of intracranial emergencies during pregnancy which needed urgent neurosurgical treatment. PATIENTS AND METHODS Data of all pregnant women who presented with newly diagnosed intracranial pathologies and neurological symptoms caused by these pathologies in an emergency setting were collected over a 10-year period (2008-2018). Patient characteristics including maternal age, gestational age, and preoperative work-up of both mother and fetus were recorded. Furthermore, the surgical treatment, mode of delivery, and neonatal and maternal outcomes were analysed. RESULTS The mean maternal age was 32.7 years and most patients were in their third trimester. There was one twin pregnancy (total of 12 fetuses). Five out of eleven pregnant women suffered from intracerebral haemorrhage (epidural haematoma (1), arteriovenous malformation (1), subarachnoid haemorrhage (2) and intracerebral haemorrhage (1)) and the other six patients had intracranial neoplasms (primary meningeal sarcoma (1), trigeminal schwannoma (1), anaplastic astrocytoma (2), glioblastoma (1) and sphenoid wing meningioma (1)).Neurosurgical procedures were performed via craniotomies in eight patients. A stereotactic biopsy via a frontal burr hole was achieved one patient. The two other patients with subarachnoid haemorrhage due to rupture of PICA aneurysms were treated with coil embolization. Depending on the gestational age and the clinical condition of the pregnant women it was decided to perform an emergency Caesarean section prior to further therapeutic measures in seven patients. Two out of 12 fetuses were unviable. Six women survived, while five women succumbed to the intracranial pathology. CONCLUSION The individualized treatment approach in this peculiar obstetric scenario needs to consider various issues such as the clinical condition of the pregnant woman, prognosis of the disease, gestational age and the status of the pregnancy. The primary concern in this context must be the mother`s health and safety. Caesarean section is the primary mode of delivery in most cases. While contemporary care can insure survival for the majority of infants, maternal mortality still poses an extraordinary challenge. Interdisciplinary consulting of the patient and/or her family is necessary to develop a treatment strategy for both the expectant woman and her offspring.
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Affiliation(s)
| | - Nesrin Uksul
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Bujung Hong
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | | | - Dirk Scheinichen
- Department of Anaesthesiology, Hannover Medical School, Hannover, Germany
| | - Josef M Lang
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Elvis J Hermann
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Peter Hillemanns
- Department of Gynaecology & Obstetrics, Hannover Medical School, Hannover, Germany
| | - Joachim K Krauss
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
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Katsuragi S, Suzuki R, Toyoda K, Neki R, Miyamoto S, Iihara K, Takahashi J, Ikeda T, Yoshimatsu J. Stroke during pregnancy and puerperium among Japanese women: a single-center registry. J Matern Fetal Neonatal Med 2019; 34:2957-2964. [PMID: 31575321 DOI: 10.1080/14767058.2019.1675626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Stroke is one of the major causes of maternal death. This study aimed to analyze the maternal and fetal outcomes of stroke occurred during pregnancy and puerperium. METHODS We conducted a retrospective analysis of patients admitted to our perinatology center between 1982 and 2012 with a diagnosis of acute cerebral stroke during pregnancy or within 6 weeks postpartum. RESULTS Thirty-four patients were registered and all the patients had never been diagnosed as stroke nor detected cerebrovascular abnormalities before the current pregnancies. They were divided into 8 ischemic strokes (ISs) and 26 intracranial hemorrhage group. In the hemorrhage group, there was a spontaneous abortion and two patients chose artificial abortions to avoid rehemorrhage, and there were another three intrauterine fetal deaths (IUFDs) in the acute stage of maternal stroke. More patients in hemorrhage group delivered in preterm than in IS group for the treatment of stroke, 10/23 (43%) versus 0/8 (0%), p < .05. More patients in hemorrhage group had low Glasgow Coma Scale (GCS) (3-8) than in IS group at the onset of the stroke, 12/26 (46%) versus 0/8 (0%), p < .05. There were three maternal deaths and 6/23 (26%) were neurologically dependent in hemorrhage group in the chronic stage, whereas 87% were independent in IS group, p < .05. CONCLUSIONS Hemorrhagic stroke was more common etiology of stroke related to pregnancy than IS in this study. Intensive and multidisciplinary care was needed especially in hemorrhagic stroke related to pregnancy as in the hemorrhagic stroke the fetal survival rate was lower, and maternal conscious levels at the onset of the stroke and neurological outcomes in the chronic stage were worse than IS.
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Affiliation(s)
- Shinji Katsuragi
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Japan.,Department of Obstetrics and Gynecology, Sakakibara Heart Institute, Tokyo, Japan
| | - Rieko Suzuki
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Reiko Neki
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Susumu Miyamoto
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Koji Iihara
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Jun Takahashi
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University, Mie, Japan
| | - Jun Yoshimatsu
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Japan
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13
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Affiliation(s)
- Eliza C Miller
- From the Department of Neurology, Division of Stroke and Cerebrovascular Disease, Columbia University Irving Medical Center, New York, NY
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14
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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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15
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Inayama Y, Kondoh E, Chigusa Y, Io S, Funaki T, Matsumura N, Miyamoto S, Mandai M. Moyamoya Disease in Pregnancy: A 20-Year Single-Center Experience and Literature Review. World Neurosurg 2018; 122:684-691.e2. [PMID: 30347298 DOI: 10.1016/j.wneu.2018.10.071] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/08/2018] [Accepted: 10/09/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Pregnancy is a potential risk factor for stroke in women with Moyamoya disease. However, the rarity of the disease has limited clinical expertise to ensure a healthy pregnancy. The aim of the present study was to explore the possible risk factors for hemorrhagic and ischemic stroke in pregnant women with Moyamoya disease. METHODS A retrospective review of cases in our hospital during a 20-year period and a review of the reported data were conducted to investigate pregnancy-related cerebrovascular events in women with Moyamoya disease. RESULTS Thirty pregnancies in 20 women with Moyamoya disease were identified in the case review of our hospital. All were previously diagnosed cases, and no stroke had occurred during the study period. In the reported data review, pregnancy-related stroke in women with Moyamoya disease was identified in 54 (44 intracranial hemorrhage and 10 cerebral infarction). Intracranial hemorrhage occurred most commonly during the antepartum period (n = 39; 88.6%), with most events occurring at ≥24 weeks. Of the intracranial hemorrhage cases, 7 (15.9%) were complicated by hypertensive disorders of pregnancy, and 8 patients (18.2%) died of stroke. The onset of cerebral infarction was either in the antepartum (n = 4; 40.0%) or postpartum (n = 6; 60.0%) period. All postpartum cases occurred within 3-7 days after delivery. CONCLUSION Pregnancy-related stroke in patients with Moyamoya disease might be susceptible to gestational age. Intracranial hemorrhage is prone to occur during the antepartum period, especially at ≥24 weeks, and cerebral infarction tends to occur postpartum.
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Affiliation(s)
- Yoshihide Inayama
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Eiji Kondoh
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Yoshitsugu Chigusa
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shingo Io
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Funaki
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Noriomi Matsumura
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masaki Mandai
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
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16
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Ladhani NNN, Swartz RH, Foley N, Nerenberg K, Smith EE, Gubitz G, Dowlatshahi D, Potts J, Ray JG, Barrett J, Bushnell C, Bal S, Chan WS, Chari R, El Amrani M, Gandhi S, Hill MD, James A, Jeerakathil T, Jin A, Kirton A, Lanthier S, Lausman A, Leffert LR, Mandzia J, Menon B, Pikula A, Poppe A, Saposnik G, Sharma M, Bhogal S, Smitko E, Lindsay MP. Canadian Stroke Best Practice Consensus Statement: Acute Stroke Management during pregnancy. Int J Stroke 2018; 13:743-758. [PMID: 30021491 DOI: 10.1177/1747493018786617] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The Canadian Stroke Best Practice Consensus Statement Acute Stroke Management during Pregnancy is the second of a two-part series devoted to stroke in pregnancy. The first part focused on the unique aspects of secondary stroke prevention in a woman with a prior history of stroke who is, or is planning to become, pregnant. This document focuses on the management of a woman who experiences an acute stroke during pregnancy. This consensus statement was developed in recognition of the need for a specifically tailored approach to the management of this group of patients in the absence of any broad-based, stroke-specific guidelines or consensus statements, which do not exist currently. The foundation for the development of this document was the concept that maternal health is vital for fetal well-being; therefore, management decisions should be based first on the confluence of two clinical considerations: (a) decisions that would be made if the patient wasn't pregnant and (b) decisions that would be made if the patient hadn't had a stroke, then nuanced as needed. While empirical research in this area is limited, this consensus document is based on the best available literature and guided by expert consensus. Issues addressed in this document include initial emergency management, diagnostic imaging, acute stroke treatment, the management of hemorrhagic stroke, anesthetic management, post stroke management for women with a stroke in pregnancy, intrapartum considerations, and postpartum management. These statements are appropriate for healthcare professionals across all disciplines and system planners to ensure pregnant women who experience a stroke have timely access to both expert neurological and obstetric care.
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Affiliation(s)
- Noor Niyar N Ladhani
- 1 Sunnybrook Health Sciences Centre, Toronto, Canada.,2 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto, Toronto, Canada
| | - Richard H Swartz
- 1 Sunnybrook Health Sciences Centre, Toronto, Canada.,3 Faculty of Medicine (Neurology), University of Toronto, Toronto, Canada
| | - Norine Foley
- 4 Department of Foods and Nutrition, Western University, London, Ontario, Canada.,5 workHORSE Consulting Group, London, Ontario, Canada
| | - Kara Nerenberg
- 6 Department of Medicine, University of Calgary, Calgary, Canada
| | - Eric E Smith
- 7 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,8 Calgary Stroke Program, Calgary, Canada
| | - Gord Gubitz
- 9 Queen Elizabeth II Health Sciences Centre, Halifax, Canada.,10 Department of Medicine (Neurology), Dalhousie University, Halifax, Canada
| | | | - Jayson Potts
- 12 Department of Obstetric General Internal Medicine, British Columbia Women's Hospital, Vancouver, Canada
| | - Joel G Ray
- 2 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto, Toronto, Canada.,13 Department of Maternal-Fetal Medicine, St. Michael's Hospital, Toronto, Canada
| | - Jon Barrett
- 1 Sunnybrook Health Sciences Centre, Toronto, Canada.,2 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto, Toronto, Canada
| | - Cheryl Bushnell
- 14 Wake Forest Baptist Stroke Center, Wake Forest Baptist Health, Winston Salem, NC, USA
| | - Simerpreet Bal
- 7 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Wee-Shian Chan
- 12 Department of Obstetric General Internal Medicine, British Columbia Women's Hospital, Vancouver, Canada
| | - Radha Chari
- 15 Faculty of Medicine & Dentistry, Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Canada
| | - Meryem El Amrani
- 16 Centre hospitalier de l'Université de Montréal, Montreal, Canada
| | - Shital Gandhi
- 2 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto, Toronto, Canada.,17 Sinai Health System, Toronto, Canada
| | - Michael D Hill
- 7 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,8 Calgary Stroke Program, Calgary, Canada
| | - Andra James
- 18 Division of Maternal-Fetal Medicine, Duke University, Durham, NC, USA
| | - Thomas Jeerakathil
- 19 Department of Medicine & Dentistry (Neurosciences), University of Alberta, Edmonton, Canada
| | - Albert Jin
- 20 Department of Medicine, Queen's University, Kingston, Canada
| | - Adam Kirton
- 7 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,8 Calgary Stroke Program, Calgary, Canada
| | - Sylvain Lanthier
- 16 Centre hospitalier de l'Université de Montréal, Montreal, Canada
| | - Andrea Lausman
- 2 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto, Toronto, Canada.,13 Department of Maternal-Fetal Medicine, St. Michael's Hospital, Toronto, Canada
| | - Lisa Rae Leffert
- 21 Department of Obstetric Anesthesia, Massachusetts General Hospital, Boston, MA, USA
| | - Jennifer Mandzia
- 22 Department of Clinical Neurological Sciences, Western University, London, Canada
| | - Bijoy Menon
- 7 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,8 Calgary Stroke Program, Calgary, Canada
| | - Aleksandra Pikula
- 3 Faculty of Medicine (Neurology), University of Toronto, Toronto, Canada.,23 Neurovascular Unit, University Health Network/Toronto Western Hospital, Toronto, Canada
| | - Alexandre Poppe
- 24 Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Gustavo Saposnik
- 3 Faculty of Medicine (Neurology), University of Toronto, Toronto, Canada.,25 Stroke Research Unit, St. Michael's Hospital, Toronto, Canada
| | - Mukul Sharma
- 26 Division of Neurology, Department of Medicine, McMaster University, Hamilton, Canada
| | - Sanjit Bhogal
- 5 workHORSE Consulting Group, London, Ontario, Canada
| | | | - M Patrice Lindsay
- 27 Heart and Stroke Foundation of Canada, Toronto, Canada.,28 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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17
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Toossi S, Moheet AM. Intracerebral Hemorrhage in Women: A Review with Special Attention to Pregnancy and the Post-Partum Period. Neurocrit Care 2018; 31:390-398. [DOI: 10.1007/s12028-018-0571-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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18
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Katsuragi S, Tanaka H, Hasegawa J, Nakamura M, Kanayama N, Nakata M, Murakoshi T, Yoshimatsu J, Osato K, Tanaka K, Sekizawa A, Ishiwata I, Ikeda T. Analysis of preventability of stroke-related maternal death from the nationwide registration system of maternal deaths in Japan. J Matern Fetal Neonatal Med 2017; 31:2097-2104. [PMID: 28610468 DOI: 10.1080/14767058.2017.1336222] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The number of stroke-related maternal deaths is increasing in Japan. We investigated methods to reduce maternal death from stroke. METHODS We analyzed stroke-related maternal deaths in Japan reported to the Committee of the Ministry of Health, Labor, and Welfare from 2010 to 2014 inclusive. RESULTS A total of 35 cases were identified. The median maternal age was 35 years (range 22-45) and the incidence of stoke in women ≥40 was seven-fold higher than in <34. Etiologies were pregnancy induced hypertension in 16, subarachnoid hemorrhage in seven, cerebral infarction in three, arteriovenous malformation in two, Moyamoya disease in one, and origin unknown cerebral hemorrhage in six. These cases occurred in antepartum 43%, in postpartum 31%, and in intrapartum 26%. 23 cases were deemed non-preventable and 12 cases preventable. Possible preventable factors occurred antepartum in 23, postpartum in seven, and intrapartum in six. Preventable features included inadequate hypertension control (33%), presenting too late for termination of pregnancy (14%), delayed hospitalization (11%), and delayed maternal transfer (11%). CONCLUSIONS A total of 90% of strokes were hemorrhagic, and older mothers (≥ 40) were most at risk. Most possible preventable factors occurred antepartum, and improved control of hypertension and earlier termination would help to reduce maternal death from stroke.
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Affiliation(s)
- Shinji Katsuragi
- a Department of Obstetrics and Gynecology , Sakakibara Heart Institute , Tokyo , Japan
| | - Hiroaki Tanaka
- b Department of Obstetrics and Gynecology , Mie University School of Medicine , Mie , Japan
| | - Junichi Hasegawa
- c Department of Obstetrics and Gynecology , St. Marianna University School of Medicine , Kanagawa , Japan
| | - Masamitsu Nakamura
- d Department of Obstetrics and Gynecology , Showa University School of Medicine , Tokyo , Japan
| | - Naohiro Kanayama
- e Department of Obstetrics and Gynaecology , Hamamatsu University School of Medicine , Hamamatsu , Japan
| | - Masahiko Nakata
- f Department of Obstetrics and Gynecology , Toho University , Tokyo , Japan
| | - Takeshi Murakoshi
- g Division of Perinatology , Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital , Hamamatsu , Japan
| | - Jun Yoshimatsu
- h Department of Perinatology and Gynecology , National Cerebral Cardiovascular Center , Osaka , Japan
| | - Kazuhiro Osato
- b Department of Obstetrics and Gynecology , Mie University School of Medicine , Mie , Japan
| | - Kayo Tanaka
- b Department of Obstetrics and Gynecology , Mie University School of Medicine , Mie , Japan
| | - Akihiko Sekizawa
- d Department of Obstetrics and Gynecology , Showa University School of Medicine , Tokyo , Japan
| | - Isamu Ishiwata
- i Ishiwata Obstetrics and Gynecology Hospital , Ibaraki , Japan
| | - Tomoaki Ikeda
- b Department of Obstetrics and Gynecology , Mie University School of Medicine , Mie , Japan
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19
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A Case Report of Maternal Cerebral Hemorrhage in Preterm Pregnancy. J Obstet Gynecol Neonatal Nurs 2017; 46:609-616. [PMID: 28599120 DOI: 10.1016/j.jogn.2017.04.135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2017] [Indexed: 11/20/2022] Open
Abstract
Intracerebral hemorrhage is a rare event during pregnancy that can result in serious morbidity and mortality for the mother and infant. In this article, we describe a case involving a multiparous woman at 34 weeks gestation who presented with a 5-cm intracerebral bleed. Within 2 hours of presenting, she underwent an emergency cesarean and craniotomy to remove the hematoma. The woman's altered mental status fully abated, and she was discharged with minimal neurologic deficits. The newborn was born healthy.
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20
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Leffert LR, Clancy CR, Bateman BT, Cox M, Schulte PJ, Smith EE, Fonarow GC, Schwamm LH, Kuklina EV, George MG. Patient Characteristics and Outcomes After Hemorrhagic Stroke in Pregnancy. CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES 2016; 8:S170-8. [PMID: 26515206 DOI: 10.1161/circoutcomes.115.002242] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hospitalizations for pregnancy-related stroke are rare but increasing. Hemorrhagic stroke (HS), ie, subarachnoid hemorrhage and intracerebral hemorrhage, is more common than ischemic stroke in pregnant versus nonpregnant women, reflecting different phenotypes or risk factors. We compared stroke risk factors and outcomes in pregnant versus nonpregnant HS in the Get With The Guidelines-Stroke Registry. METHODS AND RESULTS Using medical history or International Classification of Diseases-Ninth Revision codes, we identified 330 pregnant and 10 562 nonpregnant female patients aged 18 to 44 years with HS in Get With The Guidelines-Stroke (2008-2014). Differences in patient and care characteristics were compared by χ(2) or Fisher exact test (categorical variables) or Wilcoxon rank-sum (continuous variables) tests. Conditional logistic regression assessed the association of pregnancy with outcomes conditional on categorical age and further adjusted for patient and hospital characteristics. Pregnant versus nonpregnant HS patients were younger with fewer pre-existing stroke risk factors and medications. Pregnant versus nonpregnant subarachnoid hemorrhage patients were less impaired at arrival, and less than half met blood pressure criteria for severe preeclampsia. In-hospital mortality was lower in pregnant versus nonpregnant HS patients: adjusted odds ratios (95% CI) for subarachnoid hemorrhage 0.17 (0.06-0.45) and intracerebral hemorrhage 0.57 (0.34-0.94). Pregnant subarachnoid hemorrhage patients also had a higher likelihood of home discharge (2.60 [1.67-4.06]) and independent ambulation at discharge (2.40 [1.56-3.70]). CONCLUSIONS Pregnant HS patients are younger and have fewer risk factors than their nonpregnant counterparts, and risk-adjusted in-hospital mortality is lower. Our findings suggest possible differences in underlying disease pathophysiology and challenges to identifying at-risk patients.
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Affiliation(s)
- Lisa R Leffert
- From the Department of Anesthesia, Critical Care and Pain Medicine (L.R.L., C.R.C., B.T.B.) and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Clinical Trials Statistics Group (P.J.S.), Outcomes Research and Assessment Group (M.C.), Duke Clinical Research Institute, Durham, NC (M.C.)(M.C.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Medicine, Cardiomyopathy Center, Ronald Reagan, Ahmanson-University of California, Los Angeles Medical Center (G.C.F.); Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (E.V.K.); and Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (M.G.G.).
| | - Caitlin R Clancy
- From the Department of Anesthesia, Critical Care and Pain Medicine (L.R.L., C.R.C., B.T.B.) and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Clinical Trials Statistics Group (P.J.S.), Outcomes Research and Assessment Group (M.C.), Duke Clinical Research Institute, Durham, NC (M.C.)(M.C.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Medicine, Cardiomyopathy Center, Ronald Reagan, Ahmanson-University of California, Los Angeles Medical Center (G.C.F.); Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (E.V.K.); and Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (M.G.G.)
| | - Brian T Bateman
- From the Department of Anesthesia, Critical Care and Pain Medicine (L.R.L., C.R.C., B.T.B.) and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Clinical Trials Statistics Group (P.J.S.), Outcomes Research and Assessment Group (M.C.), Duke Clinical Research Institute, Durham, NC (M.C.)(M.C.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Medicine, Cardiomyopathy Center, Ronald Reagan, Ahmanson-University of California, Los Angeles Medical Center (G.C.F.); Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (E.V.K.); and Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (M.G.G.)
| | - Margueritte Cox
- From the Department of Anesthesia, Critical Care and Pain Medicine (L.R.L., C.R.C., B.T.B.) and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Clinical Trials Statistics Group (P.J.S.), Outcomes Research and Assessment Group (M.C.), Duke Clinical Research Institute, Durham, NC (M.C.)(M.C.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Medicine, Cardiomyopathy Center, Ronald Reagan, Ahmanson-University of California, Los Angeles Medical Center (G.C.F.); Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (E.V.K.); and Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (M.G.G.)
| | - Phillip J Schulte
- From the Department of Anesthesia, Critical Care and Pain Medicine (L.R.L., C.R.C., B.T.B.) and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Clinical Trials Statistics Group (P.J.S.), Outcomes Research and Assessment Group (M.C.), Duke Clinical Research Institute, Durham, NC (M.C.)(M.C.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Medicine, Cardiomyopathy Center, Ronald Reagan, Ahmanson-University of California, Los Angeles Medical Center (G.C.F.); Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (E.V.K.); and Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (M.G.G.)
| | - Eric E Smith
- From the Department of Anesthesia, Critical Care and Pain Medicine (L.R.L., C.R.C., B.T.B.) and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Clinical Trials Statistics Group (P.J.S.), Outcomes Research and Assessment Group (M.C.), Duke Clinical Research Institute, Durham, NC (M.C.)(M.C.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Medicine, Cardiomyopathy Center, Ronald Reagan, Ahmanson-University of California, Los Angeles Medical Center (G.C.F.); Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (E.V.K.); and Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (M.G.G.)
| | - Gregg C Fonarow
- From the Department of Anesthesia, Critical Care and Pain Medicine (L.R.L., C.R.C., B.T.B.) and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Clinical Trials Statistics Group (P.J.S.), Outcomes Research and Assessment Group (M.C.), Duke Clinical Research Institute, Durham, NC (M.C.)(M.C.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Medicine, Cardiomyopathy Center, Ronald Reagan, Ahmanson-University of California, Los Angeles Medical Center (G.C.F.); Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (E.V.K.); and Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (M.G.G.)
| | - Lee H Schwamm
- From the Department of Anesthesia, Critical Care and Pain Medicine (L.R.L., C.R.C., B.T.B.) and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Clinical Trials Statistics Group (P.J.S.), Outcomes Research and Assessment Group (M.C.), Duke Clinical Research Institute, Durham, NC (M.C.)(M.C.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Medicine, Cardiomyopathy Center, Ronald Reagan, Ahmanson-University of California, Los Angeles Medical Center (G.C.F.); Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (E.V.K.); and Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (M.G.G.)
| | - Elena V Kuklina
- From the Department of Anesthesia, Critical Care and Pain Medicine (L.R.L., C.R.C., B.T.B.) and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Clinical Trials Statistics Group (P.J.S.), Outcomes Research and Assessment Group (M.C.), Duke Clinical Research Institute, Durham, NC (M.C.)(M.C.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Medicine, Cardiomyopathy Center, Ronald Reagan, Ahmanson-University of California, Los Angeles Medical Center (G.C.F.); Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (E.V.K.); and Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (M.G.G.)
| | - Mary G George
- From the Department of Anesthesia, Critical Care and Pain Medicine (L.R.L., C.R.C., B.T.B.) and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Clinical Trials Statistics Group (P.J.S.), Outcomes Research and Assessment Group (M.C.), Duke Clinical Research Institute, Durham, NC (M.C.)(M.C.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Medicine, Cardiomyopathy Center, Ronald Reagan, Ahmanson-University of California, Los Angeles Medical Center (G.C.F.); Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (E.V.K.); and Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (M.G.G.)
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Lin LT, Tsui KH, Cheng JT, Cheng JS, Huang WC, Liou WS, Tang PL. Increased Risk of Intracranial Hemorrhage in Patients With Pregnancy-Induced Hypertension: A Nationwide Population-Based Retrospective Cohort Study. Medicine (Baltimore) 2016; 95:e3732. [PMID: 27196496 PMCID: PMC4902438 DOI: 10.1097/md.0000000000003732] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Pregnancy-induced hypertension (PIH) may be a major predictor of pregnancy-associated intracranial hemorrhage (ICH). However, the relationship between PIH and long-term ICH risk is unknown.The objective of the study was to determine the association between PIH and ICH and to identify the predictive risk factors.Patients with newly diagnosed PIH were recruited from the Taiwan National Health Insurance Research Database. PIH patients were divided into gestational hypertension (GH) and preeclampsia groups. The 2 groups were separately compared with matched cohorts of patients without PIH based on age and date of delivery. The occurrence of ICH was evaluated in both cohorts. The overall observational period was from January 1, 2000 to December 31, 2013.Among the 23.3 million individuals registered in the National Health Insurance Research Database, 28,346 PIH patients, including 7390 with GH and 20,956 with preeclampsia, were identified. The incidences of ICH were increased in both groups (incidence rate ratio [IRR] = 3.72 in the GH group, 95% confidence interval [CI] 3.63-3.81, P < 0.0001 and IRR = 8.21 in the preeclampsia group, 95% CI 8.12-8.31, P < 0.0001, respectively). In addition, according to the results of stratification of follow-up years, both groups were associated with a highest risk of ICH at 1 to 5 years of follow-up (IRR = 11.99, 95% CI 11.16-12.88, P < 0.0001 and IRR = 21.83, 95% CI 21.24-22.44, P < 0.0001, respectively). After adjusting for age, parity, severity of PIH, number of PIH occurrences, gestational age, and comorbidities in the multivariate survival analysis using Cox regression model, age ≥30 years (hazard ratio [HR] 1.99, 95% CI 1.27-3.10, P = 0.0026), patients with preeclampsia (HR 2.18, 95% CI 1.22-3.90, P = 0.0089), multiple PIH occurrences (HR 4.08, 95% CI 1.85-9.01, P = 0.0005), hypertension (HR 4.51, 95% CI 1.89-10.74, P = 0.0007), and obesity (HR 7.21, 95% CI 1.58-32.84, P = 0.0107) were independent risk factors for the development of ICH among patients with PIH.Patients with PIH, especially those with older age, preeclampsia, and multiple PIH occurrences, may have an increased risk of developing ICH later in life.
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Affiliation(s)
- Li-Te Lin
- From the Department of Obstetrics and Gynecology (L-TL, K-HT, W-SL), Kaohsiung Veterans General Hospital; Department of Biological Science (L-TL, K-HT, J-TC), National Sun Yat-sen University, Kaohsiung; Department of Obstetrics and Gynecology (L-TL, K-HT, W-SL), National Yang-Ming University School of Medicine, Taipei; Department of Gastroenterology (J-SC), Kaohsiung Veterans General Hospital; Section of Critical Care and Cardiovascular Medical Center (W-CH), Kaohsiung Veterans General Hospital, Kaohsiung; Department of Obstetrics and Gynecology (W-SL), National Defense Medical Center, Taipei; and Research Center of Medical Informatics (P-LT), Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
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A clinical characteristic analysis of pregnancy-associated intracranial haemorrhage in China. Sci Rep 2015; 5:9509. [PMID: 25819941 PMCID: PMC4377582 DOI: 10.1038/srep09509] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 03/05/2015] [Indexed: 11/29/2022] Open
Abstract
Intracerebral haemorrhage (ICH) occurring during pregnancy and the puerperium is an infrequent but severe complication with a high mortality and poor prognosis. Until recently, previous studies have mainly focused on the effect of different treatments on prognosis. However, few studies have provided solid evidence to clarify the key predisposing factors affecting the prognosis of ICH. In the present study, based on a unique sample with a high ICH incidence and mortality rate, we described the main clinical characteristics of ICH patients and found that the prognosis of patients who underwent surgical intervention was not better than that of patients who received other treatment modalities. However, pre-eclampsia patients had higher maternal and neonatal mortality rates than other aetiology groups. Furthermore, univariate regression analysis identified onset to diagnosis time (O-D time) and pre-eclampsia as the only factors showing independent correlation with poor maternal outcomes (modified Rankin Scale, mRS ≥ 3), and only O-D time was identified as a predictor of maternal mortality. These results revealed that the aetiology of ICH and O-D time might be crucial predisposing factors to prognosis, especially for patients with pre-eclampsia. The study highlighted a novel direction to effectively improve the prognosis of pregnancy-associated ICH.
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Hasegawa J, Ikeda T, Sekizawa A, Tanaka H, Nakata M, Murakoshi T, Katsuragi S, Osato K, Ishiwata I, Kinoshita K. Maternal Death Due to Stroke Associated With Pregnancy-Induced Hypertension. Circ J 2015; 79:1835-40. [DOI: 10.1253/circj.cj-15-0297] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Junichi Hasegawa
- Department of Obstetrics and Gynecology, Showa University School of Medicine
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University School of Medicine
| | - Akihiko Sekizawa
- Department of Obstetrics and Gynecology, Showa University School of Medicine
| | - Hiroaki Tanaka
- Department of Obstetrics and Gynecology, Mie University School of Medicine
| | - Masahiko Nakata
- Department of Obstetrics and Gynecology, Toho University School of Medicine
| | - Takeshi Murakoshi
- Division of Perinatology, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital
| | - Shinji Katsuragi
- Department of Obstetrics and Gynecology, Sakakibara Heart Institute
| | - Kazuhiro Osato
- Department of Obstetrics and Gynecology, Mie University School of Medicine
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